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CANCEE 



ITS STUDY AND PREVENTION 



BY 



HOWARD CANNING TAYLOR, M.D. 

GYNECOLOGIST TO THE ROOSEVELT HOSPITAL, NEW YORK, - PROFESSOR OP CLINICAL 

GYNECOLOGY, COLUMBIA UNIVERSITY; MEMBER OF THE AMERICAN GYNECOLOGICAL 

SOCIETY, AMERICAN COLLEGE OF SURGEONS, AMERICAN SOCIETY FOR THE 

CONTROL OF CANCER, AMERICAN MEDICAL ASSOCIATION, NEW 

YORK OBSTETRICAL SOCIETY, ETC. 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1915 



^. 



*\ 



^> 



Entered according to the Act of Congress, in the year 1915, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 



AUG -51915 
;i.A40699'3 



PREFACE. 



Xo larger problem in public health confronts the 
medical profession and the laity of the civilized world 
today than that of cancer. The death of over 75,000 
people yearly in the United States, and approximately 
a proportionate number in all countries where mortality 
statistics are obtainable, is proof of this statement. 

There are two ways by which this problem can be 
approached : one is by the acquisition of more information 
regarding the disease, and the other by a better use of the 
facts now in our possession. To obtain more knowledge 
of the subject is the task of both the investigator in the 
laboratory and the clinician with his patients. To make 
more practical use of the facts relating to cancer which 
we now possess, is the duty of the clinician and of the 
patient. Throughout the entire world may be found 
institutions equipped to search for facts about cancer; 
and although even its cause remains undiscovered, addi- 
tions to our store of information are being made almost 
daily by means of their researches. There is only praise 
for the work they are doing. 

The opportunity and the obligation of the clinician 
to contribute to our knowledge of the subject are not 
grasped as clearly as they should be. Neither in this 
country nor in any other do proper statistics exist regard- 
ing cancer and the results of its treatment. It is the plain 



iv PREFACE 

duty of all practitioners to preserve more accurate records 
of patients afflicted with malignant disease. While thus 
employed in collecting additional data, it is equally the 
duty of the clinician to make the best use of those facts 
already available. Much valuable information is now 
obtainable which physicians should not only know but 
promulgate among the laity with the hope of materially 
lowering the death rate. Some cancers could be pre- 
vented, others could readily be cured. 

The object of this book is to put together these facts 
and place them within easy reach of the profession and 
of others interested in this gigantic problem. 

Throughout the following pages will be found, many 
times repeated, the statement that patients with cancer 
come too late for successful treatment. This is often the 
result of neglect of the first symptoms of the disease. 
The attempt has been made to indicate the causes of 
cancer so that it may be avoided if possible, to give 
the earliest symptoms by which the condition can 
be recognized, and to show that by early surgical 
interference, favorable results can often be obtained 
with small risk. 

H. C. T. 

New York, 191o. 



CONTENTS 



CHAPTER I. 
General Considerations. 

Cause of Cancer . 26 

Predisposition to Cancer 37 

Geographical Distribution 44 

CHAPTER II. 
Precancerous Lesions 50 

CHAPTER III. 

Contagiousness of Cancer. 

Metastases 74 

Extension by Contact or Implantation 79 

Cachexia 84 

CHAPTER IV. 

Spontaneous Cure of Cancer. 

Multiple Primary Cancers 99 

CHAPTER V. 

Carcinoma and Sarcoma of the Breast. 

Carcinoma of the Breast 103 

Sarcoma of the Breast 1 25 

CHAPTER VI. 

Carcinoma of the Uterus. 
Carcinoma Uteri and Pregnancy 163 



vi CONTENTS 

CHAPTER VII. 
Carcinoma of the Oral or Buccal Cavity. 

Carcinoma of the Tongue 176 

Carcinoma of the Cheek 183 

Carcinoma of the Palate 185 

Carcinoma of the Gums 186 

Carcinoma of the Lips 187 

Carcinoma of the Face 194 

Sarcoma of the Jaws 197 

CHAPTER VIII. 

Carcinoma of the Esophagus .... 204 

CHAPTER IX. 

Cancer of the Stomach 212 

CHAPTER X. 

Carcinoma of the Intestines — Sarcoma of the Intestines 
— Carcinoma of the Appendix — Cancer of the Rectum. 

Carcinoma of the Intestines 244 

Carcinoma of the Duodenum 247 

Carcinoma of the Jejunum and Ileum 250 

Carcinoma of the Large Intestine 251 

Sarcoma of the Intestines 264 

Carcinoma of the Appendix 268 

Cancer of the Rectum 272 

CHAPTER XL 

Carcinoma of the Gall-bladder and Ducts — Carcinoma 
of the Liver — Carcinoma of the Pancreas. 

Carcinoma of the Gall-bladder and Ducts 284 

Carcinoma of the Ampulla of Vater 291 

Carcinoma of the Liver 292 

Carcinoma of the Pancreas 297 

CHAPTER XII. 

Cancer of the Kidney, Bladder, Prostate, Penis, and Testis. 

Cancer of the Kidney 301 

Carcinoma of the Kidney 309 

Sarcoma of the Kidney 309 

Malignant Adenoma of the Kidney 310 

Carcinoma of the Urinary Bladder 310 

Carcinoma of the Prostate 315 

Carcinoma of the Penis 318 

Cancer of the Testis 320 



CANCER. 



CHAPTER I. 
GENERAL CONSIDERATIONS. 

Definition. — The word cancer is not strictly a scientific 
term, though it is in common usage both by the medical 
profession and the laity. Practically, it is synonymous 
with malignant tumor, malignant disease, and malignant 
growth. 

The word tumor is used surgically, somewhat loosely, 
to mean any circumscribed swelling, even though it is not 
a new growth. For example, the swelling and indura- 
tion of an abscess may be spoken of as a tumor. It would 
be better if the term were limited more strictly and used 
only to denote new growths. 

If, however, the term tumor is qualified by the word 
malignant, it practically always means a new growth. 
A malignant tumor means a cancer. 

The two common varieties of cancer are carcinomata 
and sarcomata. These terms are strictly scientific, 
and always indicate the same types of tumors. It is 
a mistake, however, to assume that all carcinomata or 
all sarcomata are the same, for they show the widest 
variations in their characteristics. The growth may be 
rapid or slow, metastases may form early or late, and the 
cachexia from the tumor may develop shortly after its 
onset or only after it has existed for some years. 

For example, an epithelioma of the face may be of such 
mild degree of malignancy, that it may exist for years 
2 



18 GENERAL CONSIDERATIONS OF CANCER 

and can often be cured by the simplest therapeutic 
measures, while an epithelioma of the tongue is of more 
rapid growth and more quickly passes the curative stage, 
and there is a strong tendency for it to return even 
after an extensive operation. The difference in the rate 
of growth in these two conditions is probably due to the 
difference in the location in which the growths are situated. 
On the face, the growth remains relatively quiet, and is 
not subjected to the frequent movements of a similar 
condition on the tongue. If a malignant tumor is con- 
stantly irritated or moved about, its rate of growth will 
be increased. 

A scirrhus carcinoma in the breast is of a low grade 
of malignancy; it is of relatively slow growth, and may 
last for years. A medullary carcinoma in the same loca- 
tion is of a high grade of malignancy and rapidly forms 
metastases and becomes inoperable. The difference in 
the rate of growth in these two tumors is due to the 
difference in the variety of the tumor, though they are 
both carcinomata. The scirrhus carcinoma is of small 
size, and the growth and the breast in which it is situated 
together may be smaller than the opposite normal breast. 
The medullary carcinoma forms a large tumor. 

These wide variations occur both in the carcinomata 
and in the sarcomata. It is possible, when the origin 
and cause of cancer are known, it will be found that 
there are a larger number of different varieties of cancer 
than is believed today. 

It is not easy to give a definition of a malignant 
growth or cancer; it is easier to describe its character- 
istics. 

Characteristics. — The characteristics of a cancer or of a 
malignant tumor are given by Delafield and Prudden as 
follows: 

"1. Invasion of adjacent tissues by eccentric or periph- 
eral growth. 

2. The tendency to local recurrence after removal. 

3. The formation of metastases. 



INCIDENCE AND INCREASE IN FREQUENCY 19 

4. An interference with the nutrition and general well- 
being of the body, which may give rise to a condition 
known as cachexia." 

A benign tumor does not invade the adjacent tissues, 
but displaces or pushes them before it, and when removed, 
it does not tend to return either locally or at a distance. 

A benign tumor may interfere with the general well- 
being and nutrition of the body by interfering with the 
action of important organs. For example, a benign tumor 
of the intestine may obstruct its lumen and indirectly 
interfere with the general nutrition of the body. A benign 
tumor, however, does not interfere with the general body 
nutrition by the production of toxins, as is believed to be 
the case with malignant growths. 

Incidence and Increase in Frequency. — It is generally, 
though not universally, believed that cancer is increasing. 

The following table gives the number and relative 
frequency of cancer deaths in England and Wales for 
different years since 1840: 











Proportion 


Number of 








Cancer 


of cancer 


deaths from 




Deaths 


Deaths 


deaths per 


deaths to 


cancer to 




from all 


from 


1,000,000 


living 


each 100 


Year. 


causes. 


cancer. 


population. 


population. 


deaths. 


1840 . 


359,687 


2,786 


177 


1 to 5646 


1 to 129 


1860 . 


422,721 


6,827 


343 


1 to 2915 


1 to 62 


1880 . 


528,624 


13,210 


502 


1 to 1946 


1 to 40 


1900 . 


587,830 


26,721 


828 


1 to 1207 


1 to 22 


1905' . 


520,031 


30,221 


885 


1 to 1131 


1 to 17 


1912 . 


486,939 


37,325 


1019 


1 to 980 


1 to 13 



There are several facts shown by this table. The 
fourth column shows that in 1840 there were recorded 
177 deaths, and in 1912 there were recorded 1019 deaths 
from cancer in England and Wales for each 1,000,000 of 
population. That is, there were in proportion to the 
population more than five times as many deaths recorded 
from cancer in 1912 as in 1840. 

The fifth column shows the number of population in 
which there was ;m average of 1 cancer death recorded 
in the different years. In 1840 there was 1 recorded 
death from cancer, in the average, among every oMi\ 



20 GENERAL CONSIDERATIONS OF CANCER 

population; in 1912, 1 cancer death recorded to every 980 
population. 

The sixth column shows the proportion of cancer deaths 
to those that occurred from all causes. In 1840 there was 
1 recorded death from cancer in 129 deaths from all 
causes; in 1912 the proportion was 1 to 13. 

These figures for England and Wales are similar to 
those in the United States, but show a greater fre- 
quency of cancer. In the United States registration area 
in 1912, there was recorded on the average 1 death 
from cancer in every 18 deaths from all causes and 1 
death from cancer to every 1299 of population in that area. 
Deaths from cancer under the age of thirty years are 
rare. In the United States registration area in 1912, 
of the recorded deaths over the age of thirty years, 1 
in 11.5 was from cancer; of those over forty years of age, 
1 in every 10.5 was from cancer. 

The increase in cancer deaths is shown by the mortality 
records of every country in which such records are kept. 
The increase is not only universal for all countries but 
is also practically for all organs. 

That there is an increase in the recorded death rate from 
cancer, as shown by the statistics quoted, is beyond ques- 
tion, and is accepted by all. That there is a real increase in 
cancer, and not merely an apparent one, is not so univer- 
sally believed. There are two objections that are ordi- 
narily made to the evidence of mortality records covering 
a period of years that cancer is increasing. One is that 
the number of correct diagnoses of cancer is increasing 
constantly, and the other is that the average duration of 
life is longer and a larger number of people live to the 
cancer age. 

More accurate diagnoses are undoubtedly made at 
present than in 1840. These errors in diagnosis, however, 
were both positive and negative. Benign tumors were 
diagnosed as cancers, and malignant growths were not 
recognized as such. One error, at least, in part counter- 
balanced the other. 



INCIDENCE AND INCREASE IN FREQUENCY 21 

While there has been a great improvement in diagnoses 
between 1840 and the present, there has probably been 
little or none during the past five years to explain the 
increase of this more recent period. Furthermore, the diag- 
nosis of cancer at the terminal stage, which is the stage 
at which the diagnosis for the mortality statistics is 
made, is not difficult, and in communities such as England 
and Wales it was probably made with as great accuracy 
in the past as at present. At present, early diagnoses 
are made with greater accuracy, but this improvement is 
not so evident for terminal conditions. 

The diagnosis of the terminal stage of cancer of an 
accessible organ such, for example, as the breast, is so 
easy that those made in the past can hardly be questioned. 
Hoffman found that cancer of the breast in Rhode Island 
from the period 1876-1880 to that of 1896-1900 had 
increased 115 per cent. Also in Philadelphia, from the 
period 1861-1865 to that of 1896-1900, cancer of the 
breast increased 179 per cent. It is impossible to ex- 
plain this increase in cancer of an accessible organ in 
any considerable part by mistaken diagnoses. The 
periods covered are too recent and the diagnosis too 
easy. 

It must be accepted in general that more accurate 
diagnoses can explain only a small part, if any, of the 
increase in the recorded cancer death rate. 

The increased average duration of life is a factor of 
influence in the increase of cancer. Beyond question, 
if a larger number of people live to the cancer age, more 
of them will develop cancer. Statistics show that the 
increased average duration of life is due largely to prevent- 
ing the deaths of infants and young children, and that the 
frequency of deaths for later age periods remains practi- 
cally the same as in years past. It has been shown that 
for these later age periods the percentage of cancer deaths 
is constantly increasing. That is, there has been a 
constantly increasing percentage of deaths from cancer 

among people of the cineer age. 



22 GENERAL CONSIDERATIONS OF CANCER 

This excludes the longer duration of life as an explana- 
tion of the increased recorded cancer death rate. 

The influence of the modern treatment of cancer must 
have an effect on mortality statistics in the opposite 
direction to that for which better diagnoses and longer 
lives are urged. Unfortunately, the percentage of cancers 
that are cured is small, but in the aggregate they constitute 
a large number and would increase the number of cancers 
recorded. 

Correct statistics on cancer deaths are probably also 
affected by the tendency still existing for physicians not 
to sign cancer as a cause of death. To many, cancer 
is considered a loathsome disease, one which places a 
stigma on the family, and the physician assists in its 
concealment. 

There are other facts in regard to cancer, which are 
clinical and not entirely statistical, which add evidence 
to the increase of cancer. There is ample clinical evidence 
that cancer is rare among uncivilized people, and as 
they depart from their primitive mode of living, cancer 
appears and soon rapidly increases. An excellent example 
of this is given elsewhere in the description of cancer in 
Australia. The world is becoming more and more 
civilized, that is, it is departing more and more from a 
primitive mode of living, and if civilization increases the 
frequenc}^ of cancer, as is generally believed, then of 
course cancer must be on the increase. 

The departure from a primitive mode of living is 
relative. The change in the mode of living from savage 
to civilized life among the aborigines in Australia is no 
greater than has taken place in the last two generations 
of civilized Europe and America. The increased wealth, 
the trend toward the city life, with less exercise, over- 
eating, indoor life, etc., of the past two generations has 
made relatively greater changes among civilized people 
than has occurred from other causes among uncivilized 
races, and these changes undoubtedly account for at least 
a part of the increased cancer death rate. 



THEORIES OF CANCER 23 

A specific example which is caused by these changes, 
and about which there can be no doubt, is carcinoma of 
the stomach. There is no clinical doubt that gastric 
ulcer results frequently from overeating associated with 
worry and an indoor, inactive life, conditions of modern 
civilized city life, nor that gastric ulcer in a certain per- 
centage of cases becomes a gastric cancer. 

Carcinoma of the stomach is a frequent form of cancer 
and constitutes an important percentage of the total 
cancer cases. If it is caused by a gastric ulcer which is the 
result of modern eating and living, of which clinically 
there is no doubt, then it must be accepted that it is 
increasing. 

Similar evidence exists for gall-bladder, the intestines, 
and other organs. 

Taking all the evidence for and against the increase 
in cancer, it must be accepted not only that it is increas- 
ing but that it is doing so very rapidly. Also that the 
frequency of cancer is greater than mortality statistics 
indicate. 

There is evidence that the increase in the death rate 
from cancer is more rapid in men than in women. 

Theories of Cancer. — -While the cause of cancer is un- 
known, there are various theories in regard to it, 
though none of them are entirely satisfactory in ex- 
plaining all the known facts in regard to it. They 
assist, however, in giving a clearer conception of the 
cancer process. 

Cohnheim's Theory. — This is based on the theoretical 
existence of misplaced embryonal cells. There are many 
examples of congenital defects and malformations in the 
Ion nation of the body, such, for instance, as bronchial 
clefts, undescended testes, moles, nevi, etc. It is known 
that these congenital malformations are prone to undergo 
malignant change. 

Cohnheim believed, just as there are macroscopic 
malformations, so also, in the formation of the different 
kinds of tissues, there are microscopic malformations in 



24 GENERAL CONSIDERATIONS OF CANCER 

the form of displaced cells in which cancer subsequently 
develops. 

As malignant tumors do not usually develop until 
mature years, it is necessary to give explanation of this 
period of quiescence. It is known that certain senile 
changes occur in the tissues with advancing years. These 
changes occur earlier in some organs than in others. After 
the menopause, the breast and uterus, having completed 
their functions, begin a retrogressive process and it is at 
this period that carcinoma is most common in these organs. 
These same or similar changes occur at earlier periods 
from various causes, such as chronic inflammation, scar 
tissue, injuries, etc. 

It is believed that the period of quiescence is caused by 
the growth of these displaced embryonal cells of Cohn- 
heim's hypothesis being held in check and prevented 
from increasing by the control of the surrounding tissue 
cells. If this control is disturbed by the tissue changes 
of age, inflammation, irritation, etc., the growth of the 
displaced embryonal cells, no longer held in check, form 
the malignant growth. Once the malignant growth has 
started, it can be controlled no longer, and the ordinary 
clinical picture of a malignant growth is soon seen. 

The hypothesis of Cohnheim will explain some of the 
facts in regard to cancer, but it has weak points. 

That there were displaced embryonal cells at the point 
at which the cancer started is necessarily entirely theo- 
retical. No one has ever actually seen the beginning 
of a carcinoma in such cells. 

Cohnheim's theory of displaced cells does not explain 
the frequent development of cancer in scars, .r-ray burns, 
chronic inflammations, etc. 

In addition to the displaced embryonal cells, the 
existence of which is theoretical, it is, in Cohnheim's 
theory, necessary to have also some excitant, such as 
chronic inflammation, irritation, etc., to cause the malig- 
nant growth to develop. 



THEORIES OF CANCER . 25 

Ribbert's Hypothesis. — Ribbert accepted the idea of 
displaced cells as a cause for cancer but did not believe 
that the displacement was necessarily of congenital origin. 
He believed that, as a result of irritation, interference 
with wound healing, etc., that tissue cells may become 
displaced, and that under some conditions, the growth 
of these displaced cells is held in check, but in other cases, 
on account of diminished resistance, these cells grow and 
proliferate and the malignant tumor is the result. 
Ribbert's theory is an extension of Cohnheim's, to include 
not only displaced embryonal cells but all displaced cells, 
whether from developmental processes or from accidental 
disturbances of postfetal life. 

It is believed that the intitial change is not in the 
epithelial cells but in the connective tissue. As a result 
of inflammation, trauma, etc., there is a hyperplasia 
of the connective tissue which leads to the separation of 
epithelial cells from their original organic connection and 
also from the control with which they were associated. 
The removal of this control allows the abnormal growth 
of the epithelial cells, which is the malignant tumor. 

Parasitic Theory. — Neither Cohnheim's theory nor 
Ribbert's modification of it gives>a real exciting cause for 
the development of the malignant growth. They both 
describe theoretical cells, which are believed to change 
from a benign or dormant condition to a malignant one, 
but they do not give the cause of the change. 

The parasitic theory supplies this exciting cause by 
the supposition that malignant growths are caused by 
living microorganisms. This theory, however, is now 
held by few scientists. Bacteria have been found in and 
about malignant growths, but there is insufficient evidence 
that they were concerned in the formation of the tumor. 
Certain bodies have been found in and between tumor 
cells and for a time it was believed by some that they 
were living organisms and that they were concerned 
in the development of the growth. It is now generally 
held that these bodies are not living organisms, and that 



26 GENERAL CONSIDERATIONS OF CANCER 

they have nothing to do with the formation of the growth. 
These bodies in most cases are probably natural products 
of the growth or of the degeneration of the cells themselves 
or of their nuclei. 

There have been no organisms found that have been 
accepted by pathologists in general as the cause of cancer. 
The various bodies that have been reported as living 
organisms and the probable cause of cancer have been 
subsequently proved to be something else. 

Recently, Rous has discovered a filterable agent which 
causes a spindle-cell sarcoma in chickens. This at least 
suggests that there is a definite virus for this particular 
tumor. It is possible that it may be produced by a 
microorganism. 

The absence of microscopic and laboratory proof of 
the parasitic nature of cancer has forced the believers 
in this theory to clinical experience for evidence to prove 
the theory. This evidence has been insufficient. It is 
based on the possible infectiousness of cancer, as shown 
by cases of cancer a deux, cancer houses, streets, districts, 
etc. As stated in the section on infectiousness of cancer, 
all these conditions can be explained in other ways and 
there is little or no evidence that cancer is contagious. 

It is possible that in the future, a parasite or living 
organism will be found to be the cause of cancer. The 
discovery of the cause of syphilis, and the resemblance 
of cancer in some respects to this disease, has made this 
seem more probable to some observers. 

Up to the present time, however, that cancer is caused 
by a microorganism is a theory only and not an estab- 
lished fact. 

CAUSE OF CANCER. 

The real cause of cancer is still one of the unsolved 
problems of scientific medicine. The great frequency of 
the disease, effecting people of all classes in all civilized 
countries has directed the attention of the laity, the pro- 



CAUSE OF CANCER 27 

fession and even governments to the great importance of 
solving this problem. In all parts of the world there are 
well-equipped laboratories searching for the cause. 

While the real cause has not been discovered, there are 
many facts that are well known to the men in the profes- 
sion who have directed their attention to the study of 
cancer. It is possible that a more extended knowledge 
of these facts, and the proper attention to them, would be 
of as great service to humanity as the discovery of the 
cause itself. 

Chemical Irritation. — There are a number of irritating 
substances which, by constant contact with parts of the 
body (for example, the hands of workmen), have a definite 
influence in the production of cancer. The irritation first 
produces a lesion, usually an ulceration, which is not 
malignant, but later, as a result of continued irritation, 
takes on a cancerous quality. The most frequent irrita- 
tion in this class is soot and other products of the com- 
bustion of coal, guano, lead, tar, paraffin, aniline dyes, 
creosote, etc. Workers in these substances develop sores 
on their hands or elsewhere which are the starting-points 
of cancerous growths. 

Soot. — As early as 1775 Pott described an ulcerative 
process which was common on the scrotum of chimney 
sweepers, and which he designated as "chimney-sweepers' 
cancer." The most typical and classical location of this 
growth is the under side of the scrotum, but a similar 
condition caused by the irritation of soot occurs on the 
face and hands, in fact, anywhere that there may be the 
continued irritation of the soot. For example, on the 
hands and face of men who work in the soot, or at furnaces 
or in coal mines. 

The typical "chimney-sweepers' cancer" begins in the 
lower and posterior surface of the scrotum. At first it 
is an ulceration limited to the scrotum and is not unlike 
a syphilitic condition. Later it ulcerates more deeply 
and may involve the testicle and then works upward 
along the spermatic cord to the abdominal cavity. The 



28 GENERAL CONSIDERATIONS OF CANCER 

inguinal glands may be involved. The growth is slow 
and, as the condition is of a low grade of malignancy, 
its early removal ordinarily resulted in a cure of the 
condition. In some cases the removal of one or both 
testes was necessary, in others the removal of a part of 
the scrotum was sufficient. 

The disease probably was more frequent in America 
and England than in Germany due, it was suggested, to 
burning coal in the former countries, while wood is more 
generally burned in the latter. This would indicate that 
the soot from burning coal was a more active agent in 
the causation of cancer than the soot from the combus- 
tion of wood. One of the names used to designate the 
condition was "cancer anthracine." 

At present the disease is rarely or never seen. More 
modern methods are used in cleaning chimneys, and 
greater care in regard to cleanliness, removes the soot 
and prevents the irritation from it. Finally, if an ulcer 
results as a result of irritation from soot, its possible 
significance is more generally recognized and proper 
means are taken to bring about its immediate cure. It is 
cured before it reaches the cancerous stage. 

Tar and Paraffin. — In the process of distillation for the 
purification of tar and paraffin, irritated conditions of the 
skin are produced, which in some cases later develop into . 
cancer. The condition of the skin is caused partly by the 
irritation of the substance itself and partly by the tem- 
perature to which it is raised. It is probable that the 
oily condition of the clothing is also an influencing factor. 

There is at first an acute eczema with more or less 
discharge and, later, a chronic hyperplasia with the forma- 
tion of horny outgrowths or warts which may be dis- 
colored. On this benign condition by further irritation 
the malignant growth may later develop. 

The most frequent locations for the condition resulting 
from tar and paraffin irritations are the scrotum and the 
arms. There is a marked predisposition to the disease 
in some people. Some men go for years without showing 



CAUSE OF CANCER 29 

any irritation from work in these substances, while others 
are more susceptible and can work but a short time 
without developing the first signs of the disease. 

There is no question that absence of cleanliness is an 
important factor in causing the disease. At present, 
on account of better hygienic care of the workmen, the 
disease is less frequently seen. 

The course of the disease is slow, metastases are formed 
only late, if at all, and the removal of the growth usually 
effects a cure. 

Tobacco. — Smoking of tobacco has long been considered 
an important factor in the production of cancer of the lip 
and of the tongue. Formerly the influence of smoking as 
a cause of cancer of the lip was assigned to the irritation 
of the stem of a clay pipe. While this is still considered a 
factor, the chemical irritation of the hot tobacco smoke, 
that is, of the products of combustion of the tobacco, is 
probably the more important factor, especially in carci- 
noma of the tongue. 

Here, again, there is produced first a lesion which is not 
cancerous. It is at this early stage that the disease should 
be treated. By ceasing to smoke the benign lesion will 
usually heal, while if the smoking is continued, the benign 
lesion may become malignant. If this benign lesion 
on the lip or tongue does not heal by the cessation of 
smoking, then it should be removed, as the sure way of 
preventing its changing its character and becoming a 
malignant growth. The work of Bloodgood has shown 
how universally successful is the treatment of these cases 
at this stage. 

The removal of such a lesion can be accomplished 
easily under a local anesthestic with little or no remaining 
deformity. 

Physical Irritation. — The two most interesting agents in 
the production of cancer, through physical irritations, 
are the weather and .r-rays. As in the case of the car- 
cinomata which develop as a result of chemical irritation 
from soot, tar, paraffin, etc., there is produced first an 



30 GENERAL CONSIDERATIONS OF CANCER 

irritation of the skin, a benign lesion, which later changes 
to or has developed a malignant character. 

Weather. — The skin of the face and hands of people 
who are constantly exposed to varying weather conditions 
has a thin, dry appearance, resembling that of advanced 
age. This is seen particularly in sailors, farm workers, etc., 
who are constantly out of doors in all conditions of the 
weather. By some it is described largely to the action of 
the sun's rays. More likely it is the result of the extremes 
of weather to which such people are exposed. The 
extreme heat and sun's rays during the summer and 
equally the wind, driving rain, sleet and possible freezing 
of winter, are the probable causes of this condition of the 
skin. 

In these cases there is apparently a hyperemia of the 
skin with telangiectases and aggregations of dilated 
capillaries. There may be a deposit of pigment. Later 
there is an atrophy of the connective tissue and a hyper- 
trophy of the epithelial layers. The thickened epithelium 
in places may fall off, leaving a small ulcer. This ulcer 
may be benign and easily healed or it may be the beginning 
of a malignant growth. The condition produced is very 
similar to xeroderma pigmentosum, a disease which also 
frequently leads to the formation of a carcinoma of the 
skin. 

The progress of the disease is slow, there are usually 
no metastases, and the removal of the growth or its destruc- 
tion with a proper cauterizing agent leads to a permanent 
cure. 

Rontgen Rays. — The carcinoma of the skin which results 
from the action of x-rays is of special interest, as there 
can be no doubt as to the cause and effect. The con- 
nection is so absolute that there can be no doubt that 
the cancer of the skin is the result of the .r-rays. This 
proves conclusively that certain forms of cancer, at least, 
are the result of irritation. 

According to Wolff, the first observation of a cancer 
developing as the result of x-rays was published by 



CAUSE OF CANCER 31 

Freiben in 1902. A man, aged thirty-three years, as a 
result of .x-rays, developed an ulcer on the back of the 
hand. This ulcer was at first apparently benign but 
later became malignant and necessitated an amputation 
of the arm. 

As a result of the prolonged action of the z-rays, a 
dermatitis is produced, and later an ulceration develops. 
This ulcer may become malignant. In some cases, the 
malignant condition develops after the chronic dermatitis 
has existed for some time. 

Chronic Inflammation and Ulceration. — There are in 
the literature various examples of cancers which are 
believed to have resulted from chronic inflammation. 
In some cases it is difficult to "separate the influence 
of the chronic inflammation and that of other causes 
acting at the same time. In lupus of the face, which 
is sometimes followed by cancer, in addition to the chronic 
inflammation and ulceration, there are also the scar tissue 
and the frequent small injuries, which are factors in the 
development of malignant growths, and it is not easy to 
determine which of these conditions exerts the greatest 
influence. 

In the skin in addition to lupus, chronic eczema and 
psoriasis are common diseases which might be considered 
chronic inflammations, and are sometimes followed by 
cancer. 

A more positive example of the influence of chronic 
inflammation is seen in the malignant tumors which 
develop in infected wounds. In Lowenstein's series, 
in practically no case did a cancer develop in an open 
wound which healed by primary union. In a number 
of cases, in which the wound became infected, and was 
a long time in healing, a carcinoma developed. Under 
these conditions the chronic inflammation must be con- 
sidered the exciting cause of the malignant growth. 

Another example of the influence of chronic inflamma- 
tion in producing a cancer of the skin is seen in old sinuses, 
chronic ulcers, etc. A number of cases of carcinoma 



32 GENERAL CONSIDERATIONS OF CANCER 

developing in old sinuses, both in the soft parts and those 
leading to bones, are reported in the literature. The 
same is true of chronic ulcers. A chronic ulcer frequently 
existed previous to the formation of a carcinoma of the leg. 

On the tongue, lips, and cheeks an ulceration frequently 
precedes the development of an epithelioma. This has 
been described elsewhere. 

In the stomach and intestines the most frequent 
examples of carcinoma following an ulceration are seen. 
The high percentage of gastric carcinoma at the Mayo 
Clinic, that were believed to have been preceded by an 
ulceration, is given in the chapter on Carcinoma of the 
Stomach. 

In the Fallopian tubes carcinoma is rare, but chronic 
inflammation seems to be an undoubted influence in the 
cases reported. Martin, Kleinhaus and others have called 
attention to the importance of chronic inflammation in 
these cases. 

In the uterus, carcinoma of the fundus may be the 
result of a chronic inflammation, though the evidence 
is not definite. Carcinoma of the cervix uteri, however, 
seems beyond question to be influenced by the chronic 
inflammation and the ulcerations or erosions which so 
frequently accompany it. 

In these various examples of carcinomata that have 
developed in organs that have long been inflamed or ulcer- 
ated, there usually have been other influences at work 
which may have been of equal or greater importance. 
In the cheek, the continued irritation of the teeth and in 
the entire gastro-intestinal tract the irritation of an ulcera- 
tion by food and intestinal contents may have been more 
influential than the chronic inflammation and ulceration 
themselves. 

It is probable that the real influence of chronic inflam- 
mation and ulceration is partly in changing the tissues 
so that they are more disposed to malignant disease, and 
partly that the ulceration itself acts as an irritant. 

Theilhaber believes that, as a result of the chronic 



CAUSE OF CANCER 33 

inflammation, an anemia of the mesodermal tissues is 
produced, resulting in a local condition similar to the 
general senile condition of tissues later in life, and in 
which cancer is known to be more apt to develop. The 
reason why cancer is disposed to develop in this senile 
tissue is not yet known. 

In regard to ulceration, the influence is probably 
comparable to a chronic irritation. The ulceration is 
more delicate and more easily injured than the normal 
tissue in which it is located. The repeated small injuries 
may be the exciting cause of the malignant change. In 
a hollow viscus, such as the stomach, bladder, intestine, 
etc., the ulceration with the surrounding inflammatory 
induration, will not contract and expand with the same 
uniformity as the surrounding normal tissue. This will 
keep up a continual irritation of the ulceration, particu- 
larly at the edge, the point where the malignant change 
usually starts. 

Trauma. — It cannot be stated with absolute certainty 
that there is any relationship between traumatism (that 
is, of a single injury, and not small, frequently repeated 
injuries), which would better be considered a chronic 
irritation, and a malignant growth. There is, however, 
ample clinical evidence that both sarcomata and carcino- 
mata follow single injuries. 

Williams apparently does not consider that the influence 
of trauma is as great as generally believed. Against its 
influence he urges the greater frequency of cancer among 
women, and mentions as an extreme example that 
mammary cancer occurs in the proportion of 1 male 
to 11(5 females. To the advocates of trauma as a cause 
of cancer, the comparison of the male breast with that 
of the female is not strong. 

Williams also urges against the influence of injuries as 
a cause of cancer, the fact that in the parts where injuries 
are most frequent, for example, the extremities, cancer is 
most infrequent, also that while injuries are frequently 
multiple, primary cancers arc rarely so. 
3 



34 GENERAL CONSIDERATIONS OF CANCER 

Williams, however, recognizes that traumatism is a 
factor in cancer etiology, and expresses its influence as 
"spark in contact with combustible material." 

Lowenstein published a series of 271 cases from the 
literature of malignant tumors which followed injuries. 
This series is by no means complete, nor does it correctly 
represent the frequency with which malignant growths are 
supposed to follow injuries, as most surgeons have seen 
a number of cases of cancer which seem to be the result 
of trauma. The series, however, well illustrates several 
points in regard to malignant growths resulting from injury. 

In the series, 206 cases, or 76 per cent., were males, and 
only 65, or 24 per cent., were females. Williams found 
that fatal injuries in men are 2.8 times more frequent 
than in women. It is interesting that malignant tumors, 
which were supposed to be the result of injuries, should 
be three times as frequent in men as in women, when it 
is remembered that cancer in general is more frequent 
in females. That is, while cancers are more common in 
women than in men, cancers that were believed to result 
from injuries were more frequent in men than in women, 
and in about the same proportion that injuries are more 
frequent in men than in women. This can be considered 
as confirmatory evidence that the cancers resulted from 
injuries. 

The variety of tumor which results from injury most 
frequently is sarcoma, though in general carcinomata 
are more frequent than sarcomata. In the series of 
Lowenstein, 221 cases, or 81 per cent., were sarcomata, 
and 50, or 10 per cent., were carcinomata. If the 26 
cases of cancer of the skin, of which 16 cases were car- 
cinomata and 10 cases sarcomata are excluded, 90 per 
cent, of the cases in the series were sarcomata, showing 
the much greater frequency with which this variety of 
tumor results from injury. 

The interval of time that elapsed between the injury 
and the development of each variety of tumor is shown 
for Lowenstein's series by the following table: 



CAUSE OF CANCER 35 



Interval. Sarcoma. Carcinoma. 

Under 3 months . . 72 cases 34 per cent. 4 cases 8 per cent 

3 to 6 " . . 56 " 25 " 13 " 26 



56 " 25 

6 to 12 " . . 50 " 21 

1 to 2 years ... 29 " 14 

2 to 3 " ... 12 " 5 
Later than 3 years . 2 " 1 



8 " 16 

14 " 28 
4 " 8 



The table shows that sarcomata develop more quickly 
after an injury than carcinomata. During the first 
three months, 34 per cent, of the sarcomata developed 
and only 8 per cent, of the carcinomata; within the first 
year 80 per cent, of the sarcomata and only 50 per cent, 
of the carcinomata had developed; after three years, 
only 1 per cent, of the sarcomata but 15 per cent, of the 
carcinomata developed. 

The shortest interval between the trauma in Lowen- 
stein's series and the development of a sarcoma was 
fourteen days. The history of this case, the location of 
the tumor in the scrotum, and the subsequent recurrence 
would all seem to exclude the probability of error in the 
observation. It is probable in some cases that the injury 
directed attention to a preexisting malignant growth. 
For example, a case is reported of a carcinoma of the 
pylorus which was diagnosed five weeks after an injury 
and which died ten weeks later. Such a case certainly 
suggests that the growth existed previous to the injury. 

Of the organs effected by cancer resulting from an 
injury, the bones are the most frequently involved. In 
Lowenstein's series, the bones were involved in 155, or 
57 per cent., of all cases, and of these 108, or 40 per 
cent., of all cases were in the extremities. The bones, 
particularly those of the extremities, are the parts most 
frequently injured and are also most frequently involved 
in sarcomata, the most common type of post-traumatic 
cancers. It is natural, therefore, that the largest per- 
centage of the cases should be found in the bones. 

The testis is also frequently injured, and frequently 
the seat of sarcoma. In Lowenstein's series it was 



36 GENERAL CONSIDERATIONS OF CANCER 

involved in 22 cases (21 sarcomata and 1 carcinoma), 
or 8 per cent., of all cases. 

The female breast, from its location, is frequently 
injured, and naturally one would expect it to be involved 
in a post-traumatic lesion. In Lowenstein's series it 
was involved only 9 times. It is noticeable that of these 
9 cases, 4 cases were sarcomata and 5 cases carcinomata, 
which is a much larger proportion of sarcomata than is 
found among malignant disease of the breast from all 
causes. 

Of the uterus, Lowenstein does not include any cases. 
The trauma of childbirth is usually considered to be one 
of the important causes of cancer of the cervix uteri, and 
the fact that carcinoma of the cervix uteri is rare in 
nulliparae, that is, in cervices which have not been injured, 
supports this view. 

The nature of the injury is an important factor in the 
development of a post-traumatic cancer. An incised 
wound that heals primarily is rarely followed by a cancer. 
Occasionally, as described elsewhere, a cancer may 
develop in the scar and it is usually of the carcinomatous 
variety. In Lowenstein's series, there was practically 
no case reported in which a cancer followed an incised 
wound which healed by primary union. If an incised 
wound became infected, healed slowly or ulcerated, a 
cancer sometimes resulted. The wound that resulted 
from an ulceration, a bite, or a contusion, was the more 
frequent type of open wound that caused a cancer in the 
series. 

The most frequent injury that causes a malignant 
growth is a contusion such as results from a kick, blow, 
fall, etc., and not the open wound. A cancer may also 
follow a strain such as may result from overlifting, slipping, 
or spraining a joint. 

Usually the injury is slight or at least not extensive. 
For example, of 35 cases of post-traumatic cancer of the 
bones of the upper extremities, in Lowenstein's series, 
there was a fracture apparently only in 3 cases. 



PREDISPOSITION TO CANCER 37 

Injuries seem to act directly and indirectly in the 
production of cancer. In some cases the malignant 
growth develops shortly after an injury, usually of a 
subcutaneous variety, and the malignant growth seems 
to be the direct result of the traumatism. This direct 
influence of an injury in the development of a cancer 
is illustrated by the formation of a sarcoma of the testis 
from a contusion without external wound and within a 
few weeks. In other cases, the malignant growth is the 
indirect result of the injury. The injury causes a wound 
which becomes infected or ulcerates, and the malignant 
growth is the result of the inflammation or ulceration. 
That is, the cancer seems to be caused by the chronic 
inflammation or ulceration rather than the direct result 
of the injury. This direct influence of a trauma is seen 
in an open wound that is infected and fails to heal, such 
as a bite in the cheek or a lacerated wound on the skin. 

Another indirect way in which a trauma may cause 
a malignant growth is through the formation of scar 
tissue, which, through irritation or in some unknown 
way, influences the formation of a malignant growth. 
An example of this influence of an injury is often seen 
in the breast. A carcinoma or sarcoma may develop 
in the breast at a point where a contusion was received 
one, two or more years previously and during which 
interval there had been no palpable change or only a 
slight hardening in the breast. The explanation of a case 
of this kind is that the injury produced subcutaneous 
scar tissue which acted the same as similar tissue resulting 
from a mastitis or other cause. 

PREDISPOSITION TO CANCER. 

It is not easy to determine to what extent there is 
an individual predisposition to cancer. It is generally 
accepted that some people possess a definite predisposition 
to certain diseases. Under apparently similar conditions 
sonic people will contract a disease while others will 



38 GENERAL CONSIDERATIONS OF CANCER 

escape. This may be due to a greater predisposition 
to the disease possessed by those who contracted the 
disease or to a greater immunity possessed by those who 
resisted it. This immunity may be artificially acquired, 
as by vaccination against smallpox or the use of anti- 
typhoid vaccine, or it may be acquired as the result of a 
previous attack of the same disease. 

There is some evidence that this is also true of cancer, 
that is, that some people are more liable to the disease 
than others. Among animals there is positive evidence 
that some are more susceptible than others to cancerous 
growths. For example, rats and mice, and of these certain 
species show an undoubted predisposition to malignant 
growths. Of the nature of this disposition little or nothing 
is known. Attempts have been made experimentally 
to immunize animals against the implantation of cancer 
cells. 

Among humans everyone accepts that there is greater 
disposition to cancer in middle and old age. This dis- 
position, however, is for the entire race and not for individ- 
uals. The influence of sex and heredity are subject to 
differences of opinion. 

There is no doubt of the greater susceptibility of some 
people to certain precancerous lesions, such as chronic 
eczema, irritation of skin from soot, tar, etc. In this 
indirect manner, such people might be considered as 
predisposed to skin cancer. 

Age. — A malignant tumor may occur at any age. It 
may even be congenital. They occur with increasing 
frequency, after the first five years, up to seventy-five 
or eighty years of age, and according to some observers 
up to the oldest age reached by man. That is, for the 
same number of people living at a certain age after five 
years, the greater will be the number of deaths from cancer, 
the older that age is up to eighty years, when possibly 
the number will be smaller. 

In order to get correctly the age incident of cancer, the 
number of deaths from cancer during an age period, 



PREDISPOSITION TO CANCER 39 

and also the number of people living at that period, 
must be considered. There are absolutely more deaths 
between the ages of forty and fifty years than between 
sixty and seventy years, and there are many more people 
living in the former age period. There is, however, a 
greater percentage of deaths from cancer in the latter 
period. The death rate per 10,000 population for different 
ages and age periods is illustrated by the following table 
computed from the mortality records of Prussia. Of every 
10,000 living there died of cancer in 1898, in Prussia: 

Age. Males. Females. 

Under 1 year 0.46 0.43 

1 to 2 years 0.18 0.23 

2 to 3 " 0.30 0.28 

3 to 5 " 0.27 0.27 

5 to 10 " 0.14 0.09 

10 to 15 " 0.11 0.13 

15 to 20 " 0.26 0.19 

20 to 25 " 0.33 0.45 

25 to 30 " 0.57 0.86 

30 to 40 " 1.84 3.02 

40 to 50 " 7.89 11.05 

50 to 60 " 20.70 21.37 

60 to 70 " 39.46 32.52 

70 to 80 " 36.52 34.24 

Over 80 " 26.30 26.87 

It will be noticed in this table, which is representative 
of others showing the same thing, that there is a moderate 
decrease in the number of deaths from malignant tumors 
from birth to the fifth year. This same thing is shown 
in the mortality statistics of the United States Census 
Bureau in which more deaths are recorded from malignant 
growths during the first five years than for any other 
five-year period until after the twentieth year. This is 
doubtless due to the deaths from malignant growths 
which were congenital or resulted from congenital defects. 

It will be noticed also that after the fifth year there is 
only a slight increase for each age period until thirty 
years of age, when there is a much more rapid increase 
to seventy years for men and eighty years for women, 



40 GENERAL CONSIDERATIONS OF CANCER 

at which ages there is again a decrease in the death rate. 
Some observers do not record this final decrease in the 
death rate, but believe that it continues to rise with the 
increasing age. This final decrease in the cancer death 
rate might be explained by greater care in eating, mode 
of living and freedom from accidents, irritations, etc., 
which might offset the greater disposition to malignant 
growths of the more senile tissues. 

It will also be noticed that between the ages of thirty 
and sixty years there is a larger percentage of deaths 
among women, and between sixty and eighty years it is 
larger among men. 

As has been shown by the table quoted, malignant 
tumors may occur at any age. The malignant tumors 
that occur before the twentieth year are practically all 
sarcomata. Carcinomata are rare before that age. 
Of 942 malignant tumors seen by Williams, 806 were 
carcinomata and 136 were sarcomata. Of the carcino- 
mata, only one case originated under twenty years of age. 
Of the 136 sarcomata cases, 24, or 17.5 per cent., were 
under twenty years of age at the onset of the disease. 

Of 1789 cases of sarcoma reported by Williams from 
mortality records, 261 cases, or 14.6 per cent., were 
under twenty years of age at the time of death. 

Sarcomata may occur at any age and frequently are 
congenital, but carcinomata are rare before twenty years 
of age. 

According to Williams, the earliest authentic case of 
a malignant epithelial growth was in a girl, aged eleven 
years, who had a cylindric-celled carcinoma of the rectum. 

The oldest patient known to Williams, who died of a 
malignant tumor, had a cancer of the eye and one of the 
wrist, and died at the age of one hundred and six years. 

Sex. — Sex exerts a great influence in the incidence of 
malignant growths, largely due to the frequent occurrence 
of cancer in the female breast and the uterus and the infre- 
quent occurrence in the corresponding male organs. The 
greater frequency of malignant growths in females applies 



PREDISPOSITION TO CANCER 41 

to carcinomata but not to sarcomata. For example, of 
1350 cases of sarcomata of different organs studied by 
Williams, 702 cases occurred in males and 648 cases in 
females. In 1912 in England and Wales the death rate 
from cancer was 91 per 100,000 males and 117 per 100,000 
females. 

In the United States in 1912, assuming that the rate 
for the entire country was the same as in the registration 
area, in a total of 73,611 deaths from malignant tumors, 
29,202 were in males and 44,409 in females. The sex' 
ratio was therefore about 1 male to 1.5 females, or 50 
per cent, more females than males. 

According to Williams, cancer deaths are increasing 
more rapidly in males than in females, and there is there- 
fore a decrease in the sex ratio. As determined by him, 
presumable for England and Wales, the sex ratio was for 
the period 1851 to 1860, 1 male to 2.2 females, 1881 to 
1890, 1 male to 1.7 females and from 1901 to 1905, 1 male 
to 1.3 females. 

Williams believes that the greater increase in the 
cancer death rate of males is due to more of them living 
in cities and their lives more closely resembling those of 
women, that is, more indoors, less exercise and greater 
indulgence in food. 

Heredity. — There are wide differences of opinion 
regarding the influence that heredity may play in the 
development of cancer. The earliest writers considered 
that cancer was hereditary, but of more recent years 
there have been two schools, one holding that cancer is 
hereditary and the other that it is not. Most observers 
hold that the influence of heredity is a small one, if it 
exists at all. 

A strong argument, to those who believe that cancer 
is hereditary, is the existence of "cancer families." In 
these families, members in different generations develop 
cancer in larger numbers than would be expected from 
chance. The existence of such families, though not 
frequent, are undoubted. To those who believe that 



42 GENERAL CONSIDERATIONS OF CANCER 

cancer is hereditary, these families are usually considered 
as evidence of such an influence. Those who do not 
believe that cancer is hereditary explain "cancer families" 
by chance. 

The most noted "cancer family" is that of Napoleon. 
Napoleon's father, he himself, a brother, and two sisters 
all died of cancer. 

The most extensive "cancer family" is the one reported 
by Broca, in 1866, and quoted by Wolff and by Williams. 
In this family Madame Z. died of cancer of the breast. 
She had four daughters, two of whom died of cancer of 
the liver and two of cancer of the breast. In the third 
generation, of five males and thirteen females, one male 
and nine females died of cancer. Of this family, Madame 
Z. and twenty-two descendants, eighteen died of cancer 
and five did not. 

It is possible that cancer families, as claimed by some, 
can be explained by chance. Granting, however, that 
they cannot be, and that they are evidence of the trans- 
mission of cancer by inheritance, then it must also be 
accepted that they show that the influence of heredity 
is a small one. The number of "cancer families" com- 
pared with the enormous number of cases of cancer, is 
small, much smaller than would be the case if heredity 
played an influential part in the origin of cancer. 

It would seem that the occurrence of cancer families 
could be explained better by chance than by heredity. 

Another influence in the development of cancer, which 
in a way is hereditary, is seen in certain skin conditions 
such as nevi, warts, moles, etc. It is generally accepted 
that these conditions show an hereditary tendency. It 
is also known that they may become malignant. The 
hereditary influence in these conditions is an indirect one. 
The most that can be claimed is that a lesion which has 
certain cancerous tendencies was inherited, and not the 
cancer itself. 

In the same category are cases of carcinoma of the 
skin, in which several members of the same family are 



PREDISPOSITION TO CANCER 43 

diseased. Wolff refers to a family reported by Ruder, 
in which seven boys between the ages of five months and 
ten years, all of whom developed epithelial carcinomata 
of the skin. In these cases, as with the nevi, moles, etc., 
it is probable that a skin lesion which possessed cancerous 
tendencies was inherited, and not the cancer. 

Cases of this kind constitute a small part of all cancer 
cases and here, again, at most, heredity plays a small 
part. 

The strongest argument against the inheritance of 
cancer is that the frequency with which cancer occurs 
can be explained by statistical evidence. 

Of all people who pass the age of forty years at least 
one in twelve dies of cancer. As each person has two 
parents and four grandparents, two people together would 
have twelve direct ancestors in the two previous genera- 
tions. As at least one person in twelve past the age of 
forty years dies of cancer, the chances are that of every 
two people who contract a cancer, one of them will have 
had a parent or a grandparent who had a cancer. In 
other words, the probabilities are that at least 50 per 
cent, of all cancer cases, in fact 50 per cent, of all people, 
will have a parent or a grandparent who had a cancer. 

When the side lines are also considered, that is, the 
brothers and sisters, uncles and aunts, it is obvious that 
the chances are that every person has a near blood relative 
who had a cancer. 

Additional valuable information on hereditary influence 
in the origin of cancer is obtained from mortality records 
of life insurance companies. Practically all who take 
out life insurance policies are people of intelligence, and 
the records are taken with more care than ordinary 
clinical histories. These life insurance statistics are 
therefore of great value in determining the influence of 
heredity in cancer. 

A careful study of life insurance statistics has shown 
that the cases that die of cancer have a family history 
of cancer no more frequently than those who have died 



44 GENERAL CONSIDERATIONS OF CANCER 

of other diseases. If this observation is correct, and there 
seems to be every reason to consider it so, it is strong 
evidence against heredity as an influence in cancer. 

If all the evidence for and against heredity as an in- 
fluence in cancer is considered, the probable conclusions 
are: 

1. That in most cases, heredity exerts no influence in 
cancer. 

2. That there may be possibly an exception in this in 
some families. 

3. That some precancerous lesions such as warts and 
nevi may be hereditary. 

GEOGRAPHICAL DISTRIBUTION. 

Climate. — There have been radical changes in the 
opinions of men regarding the influence of climate on the 
prevalence of cancer. At one time it was believed that 
the warm, moist climate of the tropics favored the develop- 
ment of the disease; later, the opposite opinion, that the 
cold of the north was more favorable to it. It is now 
known that cancer is found in all parts of the world, 
and it is believed that climate itself has little or no effect 
on its occurrence. There are other factors that are more 
influential in its occurrence in different countries. In the 
temperate regions there is an older and higher civiliza- 
tion, and it is this higher civilization, with all that it 
means in food, manner of living, housing, occupations, 
etc., and not climatic conditions, that is the cause of the 
higher cancer rate. 

Race. — In regard to race, there is no doubt that there 
is a difference in the prevalence of cancer among different 
races or nationalities. While it is not possible to exclude 
the climate as an etiological factor, there are other causes 
that seem to exert greater influence. Apparently the 
lower the grade of civilization the more infrequent is 
cancer. It is probable that among primitive savages, 
such, for example, as those of Central Africa, cancer is 



GEOGRAPHICAL DISTRIBUTION 45 

rare. There are, of course, no accurate statistics in regard 
to the cancer death rate among these uncivilized races, 
but the repeated observations of military surgeons and 
medical missionaries confirm this belief. As soon as the 
uncivilized races come under the influence of civilized 
life the cancer death rate increases. For example, as 
has been stated, malignant tumors among the races of 
Africa are believed to be rare; this was true of these people 
as slaves in the United States, but after the emancipation 
the cancer death rate increased and is now practically 
the same as that of the white race. As slaves their 
physical condition was carefully looked after, their work 
was largely out of doors, their food simple and not exces- 
sive, there was no overeating or drinking or general dissipa- 
tion. It was to the interest of the owner to look after his 
property. After the slaves were freed, they deteriorated 
in physical condition as a result of dissipation, overeating 
and drinking, bad housing, constitutional diseases, etc. 
These changed conditions and the increased cancer death 
rates are known, and it is probable that one is influenced 
by the other. 

The same conditions are seen in Australia, where a 
highly civilized white race is living under the same climatic, 
but different personal conditions, as a race recently and 
rapidly changing from a savage to a civilized people. 

In an interesting paper, Allen compares the cancer death 
rate of Australia for 1900 with that for 1870, and found 
that the cancer death rate of both sexes had increased from 
27.5 to 57.2 per 100,000, an increase of more than 100 per 
cent. Allen explained the increase in the frequency of 
cancer in Australia by the larger number of people living 
to the cancer age. This would doubtless explain a part 
of the increase, but not all of it. It is probably also due 
to the increased civilization of the native people, the 
greater accuracy of statistics and to the better oppor- 
tunity of the natives to obtain hospital or medical atten- 
tion. During 1000 in England and Wales the cancer death 
rate was 82.8 per loo.ooo. This would indicate that cancer 



46 GENERAL CONSIDERATIONS OF CANCER 

in 1900 was about 30 per cent, less frequent in Australia 
than in England and Wales. Allen believed cancer to 
be rare among the Australian aborigines, but that it is 
rapidly increasing among them. 

Adams studied the cancer death rate of the native, and 
of the British and foreign-born population of Australia for 
the year 1900. According to Adams, the death rate for 
1900 was 57.3 per 100,000 living inhabitants, and of this 
number 17.1 were native-born and 40.2 were British or 
foreign-born. Considering only the population over 
thirty-five years of age, the total death rate per 100,000 
population was 195.3, of which 58.2 were native-born and 
137.1 were British or foreign-born. Adams corrected 
these figures regarding the number of native, British and 
foreign-born inhabitants, and found that the cancer death 
rate for 100,000 native-born inhabitants over thirty-five 
years of age was 81.3 and for 100,000 British inhabi- 
tants over thirty-five years of age it was 490, and for 
100,000 foreign-born over thirty-five years of age it was 
351.6. These figures are of special interest, as they show 
the difference in cancer death rates of different races 
living under the same climatic conditions. 

These statistics of Allen and Adams are here of definite 
value. Those of Allen would seem to indicate the increas- 
ing cancer death rate of a native people becoming civilized. 
The figures of Adams show the higher cancer death rate 
of the more highly civilized part of the population. 

In Europe there is the highest, or perhaps better, the 
most luxurious civilization of any part of the world. 
The people are, as a whole, well nourished, most live in 
towns, many work indoors, and there is the highest 
cancer death rate. 

According to Williams, the cancer rates per 100,000 
population, about the year 1900, for different countries 
of Europe, were as follows: Switzerland, 132; Denmark, 
130; France, 104; Sweden, 102; Holland, 93; Norway, 92; 
England and Wales, 82; Scotland, 61; Italy, 52; Spain, 39. 

Williams explains the high cancer rate of Switzerland 



GEOGRAPHICAL DISTRIBUTION 47 

and Denmark by the higher average general welfare of 
the people, that they have neither the very rich nor the 
very poor. He also calls attention to the general low 
death rate from cancer along the Mediterranean shores, 
as shown by statistics quoted. 

There are so many factors that enter into cancer 
statistics that it is not possible to make absolute com- 
parisons. That the recorded cancer death rates in 
Europe are higher than in other continents is beyond 
question, and it probably indicates that the higher the 
civilization and general welfare the greater the cancer 
death rate. Williams considers that this is the only 
explanation, and that it is not possible to explain it by 
age, sex, better diagnosis, etc. In the United States 
registration area in 1912 the cancer death rate was 77 
per 100,000 population. This corresponds closely to the 
rate in European countries. 

In Africa, except in limited areas inhabited largely 
by Europeans, there are no accurate cancer statistics. 
Information regarding cancer comes largely from medical 
missionaries and army surgeons, and consists of clinical 
impressions rather than statistics. They all practically 
agree, that among the native black races cancer is unknown 
or rare. For example, Madden states that the medical 
men in Egypt agree that cancer is not found among the 
black races in that country, but that it is fairly frequent 
among the Arabs. Forde did not see a case of malignant 
tumor among natives in nine years' practice in Gambia. 
Similar statements are recorded for the native population 
throughout Africa. 

In South Africa, Williams states that cancer is fairly 
common among those who eat and live as Europeans. 
Among the natives who live a simpler, vegetarian life, 
cancer is rare. 

Various causes have been offered for the infrequent 
occurrence of cancer among the black races of Africa. 
The protection offered by the pigment of the skin, the 
relative absence of smoking, the vegetable diet, and few 



48 GENERAL CONSIDERATIONS OF CANCER 

gastrointestinal disturbances, the high infant mortality 
and the fewer people living to the cancer age, are all 
considered as possible influences. 

Of the distribution of cancer in Asia, little is definitely 
known from careful statistics. It is generally believed 
that in China, cancer is fairly frequent, but apparently 
the number of cases is not large, and the information is 
based on the reports of medical missionaries and a few 
hospitals, and not from a survey of the entire country. 
In Japan, in 1905, the cancer death rate, according to 
Buday (Wolff), was 53 per 100,000 living inhabitants. 

Cities and Country. — Even when corrected for age, sex, 
hospital facilities, and diagnosis there seems to be greater 
frequency of cancer in the inhabitants of cities than in 
the country. This is illustrated for France by the follow- 
ing rates for 1900 per 100,000 inhabitants as given by 
Williams : 

Paris 121 

Cities over 100,000 population 112 

" 30,000 to 100,000 population 99 

" 20,000 to 30,000 " 95 

" 10,000 to 20,000 " 91 

5,000 to 15,000 " 74 

" under 5000 " 82 

In Hungary, as reported by Dollinger, there is a much 
greater difference in the cancer death rate of cities and 
the surrounding country. For example, of the inhabitants 
of Budapest over fifteen years of age the rate, 1901-1904, 
was 121, while in the surrounding country it was only 
59 per 100,000. In some localities the difference was even 
greater. Dollinger also quotes the rates for Denmark 
as follows: 

Copenhagen 54 

Other cities 47 

Surrounding country 38 

In Scotland there is a slightly greater frequency among 
those living in the country than in the cities. It should 



GEOGRAPHICAL DISTRIBUTION 49 

be remembered, however, that in England and Scotland 
the difference between city and country life is not as 
marked as in some countries. 

It is not possible to explain the reason for the greater 
frequency of cancer in the cities, excepting in general 
statements. There is a tendency for people after child- 
hood to leave the country and go to the cities. This 
would mean that in 100,000 people living in the cities 
there would be a larger number of the cancer age than 
among the same number of country people. In large 
cities the hospital facilities are such that the people go 
there from the country for better care, and their deaths, 
if they occur, are recorded for the city. This is a factor 
of importance. The element of better diagnosis is one 
of less importance, because in the terminal stages the 
nature of a malignant growth is usually too evident to 
be mistaken by a practitioner of medicine. 

LITERATURE. 

Adams. Lancet, 1904, i, 422. 

Allen. Australasian Med. Gazette, 1902. 

Broca. Traite des Tumeurs, 1866, p. 151. 

Forde. Report on Cancer in British Colonies, 1905. 

Madden. British Med. Jour., 1902, ii f 730. 

Milne. British Med. Jour., 1905, ii, 925. 

Stern. Deutsch. med. Woch., xviii, S. 494. 

Williams. British Med. Jour., 1890, ii, 895. 



CHAPTER II. 
PRECANCEROUS LESIONS. 

The first use of the word precancerous was probably 
by Butlin about twenty-five years ago, when he applied 
it to certain lesions of the tongue which showed a particu- 
lar predisposition to change from a benign to a malignant 
growth, and there are today no better examples of lesions 
to which the term precancerous can properly be applied 
than to these same tongue lesions. Of late the term is 
being more commonly used. This is due partly to the 
greater interest that has developed in regard to cancer, 
but probably more particularly to the greater willingness 
of pathologists to express the opinion that a certain lesion 
is not a cancer but is a type that is liable to become one. 
It is for such a condition that the term precancerous is 
needed. 

The exact meaning of the expression should be under- 
stood. A precancerous lesion is not a cancerous lesion; 
it may not even become one. It is, however, a lesion 
of the type that is known to become cancerous in a larger 
percentage of cases than most benign lesions. The term 
is not exactly a scientific one, but it describes a definite 
condition for which there is no other concise expression. 

It is of considerable practical importance that this 
condition should be described by some concise and expres- 
sive term, because by doing so a better understanding 
of these lesions and a more frequent recognition of their 
importance will be brought about. 

It is possible by further advance in the pathology of 
malignant growths that it will be possible to determine 
more positively and more frequently what benign lesions 



TONGUE 51 

are liable to change their character and become malignant, 
and also the time when the change is taking place. This 
would add to the list of known precancerous lesions. 

The operative treatment of malignant growths is not 
satisfactory, and the constant regret of surgeons is that 
cancer cases are seen too late. It is possible that in the 
future, by more frequent recognition and cure of precan- 
cerous lesions, much can be accomplished in the preven- 
tion of cancer and also in the earlier recognition of it. 

The statistics of operation on precancerous lesions must 
not be confused with those performed for cancer. A pre- 
cancerous lesion is not a cancer, and when removed it 
shows no tendency to recur or to form metastases. If it 
did, then it was not a precancerous but a cancerous lesion. 
The percentage of cures of precancerous lesions is effected 
only by the primary operative mortality. 

The early recognition of precancerous lesions is of 
sufficient importance to group the most important ones 
together. 

Tongue. — A frequent precancerous lesion of the tongue 
is leukoplakia, also known as chronic glossitis, leukoma, 
etc. This is a chronic condition which at first resembles 
the white mark produced by a stick of nitrate of silver. 

There may at first be one or several white patches, 
which later unite and cover most of the dorsum of the 
tongue. At first the tongue is soft and pliable, but later, 
due to the thickening of the epithelium, it becomes more 
hard and rigid. If the superficial epithelium is scraped 
off there remains a red, bleeding ulcer on the tongue. 
The disease runs a chronic course and seems to yield to 
no treatment other than absolute destruction with the 
cautery. 

The two important etiological factors usually given 
for leukoplakia arc tobacco smoking and syphilis. The 
influence of the smoking is partly the burning and partly 
irritation of the products of combustion. 

Leukoplakia is most frequently seen on the tongue, 
but cases are reported in which it has occurred on the penis, 



52 PRECANCEROUS LESIONS 

lip, cheek, in the nose, larynx, bladder, vulva, and vagina. 
Wherever it occurs, it should be considered a lesion 
which is liable at any time to become cancerous, and it 
should be removed, destroyed with a cautery, or carefully 
watched for possible malignant change. 

No positive cause for the malignant change that may 
occur in leukoplakia can be given. A condition is pro- 
duced in the tongue by the leukoplakia that is easily 
injured by its normal movements, food, etc., producing 
small cracks and areas of chronic inflammation. These 
small, frequently repeated injuries and the chronic 
inflammation may exert the same influence in the tongue 
as elsewhere in the production of a malignant growth. 
It is possible that the thickened, superficial layer of 
epithelium may act as a foreign body and produce the 
malignant change by causing a chronic irritation of the 
more normal parts. 

Any ulcer of the tongue which does not heal promptly 
should be considered a possible precancerous lesion. 
The most common ulceration of this kind is one that 
appears toward the tip of the tongue and is the result of 
smoking, that is, of being repeatedly burned by a hot 
pipe stem or irritated by the hot smoke. 

Another ulceration on the tongue, which falls in this 
class, is one that may form at any place on the margin 
of the tongue from irritation of broken teeth, particularly 
if associated with syphilis and excessive smoking. 

Obviously the cure of these lesions is the removal of 
the cause. 

Cheeks. — Precancerous lesions of the same nature 
as the ulcerations which occur on the tongue may arise 
in the cheeks and on the gums. That is, there may be 
patches of leukoplakia, or ulcerations from smoking, 
broken teeth, etc. They are, however, of less frequent 
occurrence. 

Lips. — While any chronic ulceration of the lip must be 
regarded with suspicion, the most important precancerous 
lesion of the lip is one which results from smoking and 



LUPUS 53 

is occasionally known as smoker's patch. It is caused 
by repeated irritation or burning of a hot pipe-stem or hot 
smoke. It may appear first as a small blister, or as a 
crack or fissure, or as a thickened or tanned area. 

The work of Bloodgood has directed attention to the 
importance of these early lesions, and is of great value. 
He has shown that if removed at this stage they are 
all cured. It is probable that many would disappear if 
not removed; it is equally true that many would develop 
into malignant growths. 

Skin. — A number of the chronic diseases of the skin 
are believed to influence the development of cancer. 
The connection is not a close one, and it is difficult to 
prove the direct relationship between the skin disease and 
the cancer. In many cases 'the skin disease has existed 
for years previous to the appearance of anything of a 
malignant nature, and it is probable that in many cases 
it is merely a coincidence that the two diseases occur in 
the same place. 

Chronic eczema is probably more frequently followed 
by cancer than any other disease of the skin. Paget's 
disease of the nipple is frequently cited as an example 
of a malignant disease following a chronic eczema. In 
Paget's disease there is at first a lesion which has all the 
signs of a chronic eczema about the nipple. Later an 
ulceration is formed with involvement of the breast. 
Some observers, however, regard Paget's disease as malig- 
nant from the start and not related to a chronic eczema. 

Two other special locations where chronic eczema is 
apparently followed by an epithelioma is about the 
scrotum and aboift the anus. 

Lupus. — Lupus has long been regarded as a precancerous 
skin lesion. As early as the middle of the nineteenth 
century, cases of carcinoma developing on lupus as a base 
were reported. 

The lesions of lupus possess a number of characteristics 
that are believed to predispose to the formation of cancer. 
There is an ulcer which is the seat of a chronic inflam- 



54 PRECANCEROUS LESIONS 

mation. The ulcer heals in places, but the scar is an 
unhealthy one, and is frequently injured and breaks down 
to form a new ulceration. The unhealthy scar, the 
ulceration, and the chronic inflammation all predispose 
to cancer, and they are probably the influences that 
change the lupus to carcinoma. 

The carcinoma that develops on lupus may originate in 
the scar or in the ulceration itself. Some writers desig- 
nate two varieties: lupus carcinoma and lupus scar carci- 
noma, depending on the place in which the carcinoma 
originates. 

Clinically, the carcinoma that develops on lupus is 
similar to other epitheliomata of the skin. It usually 
develops after the lupus has existed for a number of 
years, and in a patient who has reached the cancer age. 
The edges of the ulceration become hard and indurated. 
In the centre the growth extends into the deeper tissues, 
forming a more extensive ulceration. In rare cases a 
papillomatous form is reported. 

Lupus vulgaris show r s a greater disposition to become 
malignant than the other varieties of lupus. 

Ulcers. — The relation of simple ulcers of the skin to 
carcinoma is not a close one. The most frequent location 
of chronic ulcers is on the lower extremities. Not only 
are ulcerations in that locality of common occurrence, 
but they are exposed to frequent. injury, and they occur 
most frequently during the cancer age, yet carcinoma 
of the extremities is of rare occurrence. A number of 
cases, however, are reported in the literature in which 
simple ulcer of the leg after persisting for a number of 
years as a benign lesion has taken on a malignant change. 
The malignant change starts and progresses from a single 
point, the edges become raised and hard, and the centre 
may at first grow more exuberantly, but later breaks 
down, forming a deeper excavation. 

While the number of cases of carcinoma of the lower 
extremities is small compared with the ulcers in that 
locality, the ulceration should be considered as a possible 



ULCERS 55 

etiological cause of the carcinoma. It is impossible to 
state the exact maimer in which its influence is exerted. 
The influences which produce and retard the healing 
of the ulceration itself are probably also factors in the 
development of the carcinoma. The chronic eczema of 
the skin, the chronic edema due to varicose veins, and the 
frequent traumatism are the most important of these 
influences. It is probable, too, that the ulceration itself, 
associated as it always is with some chronic inflammation, 
may act as a constant irritant to the tissues, and this 
irritation may influence the development of carcinoma. 

Closely resembling cutaneous ulcers in their influence 
on the development of cancer are old sinuses. According 
to Wolff, the tuberculous sinus and that associated with 
osteomyelitis are most apt to develop a malignant change. 
Wolff also refers to cases reported in the literature of 
either sarcoma or carcinoma developing in a fistula in 
ano, in a urethral fistula, and in the sinus resulting from 
a gunshot wound with retention of the bullet. None of 
these cases are frequent, but of all cases of epitheliomata 
of the extremities a large percentage of them develop in 
chronic ulcers. 

Frequent examples of carcinomata developing in pre- 
existing simple ulcerations are seen in the stomach, 
and there is at present a free discussion among surgeons 
and pathologists in regard to the frequency with which 
this malignant change occurs in gastric ulcers. That such 
a change does occur there is ample clinical and laboratory 
proof, and no doubt is raised in regard to it. The frequency 
with which it occurs is more difficult to determine. At 
the Mayo Clinic it is reported from independent clinical 
and laboratory examinations that considerably over 50 
per cent, of all cases of carcinoma of the stomach developed 
on a simple ulcer. This estimate is much higher than is 
generally accepted. Most surgeons estimate that between 
5 ;mkI 25 per cent, of the gases of gastric cancer were 
preceded by an ulceration. 

There are no statistics which give the frequency with 



56 PRECANCEROUS LESIONS 

which a gastric ulcer changes from a benign to a malignant 
condition. These statistics would be difficult to obtain, 
but would be of great practical importance. There is no 
doubt that the number is only a small percentage of all 
cases of gastric ulcer. 

There are several possible causes which influence the 
change of a gastric ulcer from a benign to a malignant 
lesion. As has been stated in regard to ulcers of the 
extremities, the gastric ulcer itself is associated with 
chronic inflammation which predisposes the tissues to 
malignant growth. In addition a gastric ulcer is sub- 
jected to the irritation, both physical and chemical, of 
food and stomach contents, and also to the movement of 
the organ. 

Scars. — According to Wolff, the first published observa- 
tion of a carcinoma developing in a scar was made by 
McPherson as early as 1844. There have since been many 
observations of carcinoma developing in scars and various 
theories advanced to explain them. 

There are some scars which show little or no tendency 
to develop malignant change; there are others that show 
a marked tendency to do so. 

The rupture of the hymen leaves a scar, but a carcinoma 
rarely develops in this location. In women who have borne 
children there are scars in the vagina, but carcinoma 
rarely follows. In this group there would also be included 
the scar of the penis following circumcision, of the ovaries 
following frequent rupture of Graafian follicles, of the 
hands of workmen following frequent injuries. 

Carcinomata may occur in any of these, but only rarely 
in comparison with the frequency of the scars. These 
scars are all entirely healed, and might be termed healthy 
scars. 

In the second group of scars, carcinomata develop 
more frequently. The first places in this group of scars 
are those which are the result of burns, particularly if 
the scar is located so that it is frequently injured. An- 
other scar, probably of equal importance, is that of the 



SCARS 57 

cervix uteri resulting from childbirth. In this group are 
included the scars of ulcers, particularly if not entirely 
healed, such as those of the leg or stomach, also mastitis, 
syphilis, and lupus. These scars are less healthy than 
those of the former group. 

The period of time that elapses between the formation 
of the scar and the development of the carcinoma varies 
greatly. It may be only a short time, that is, a few months, 
but usually it is at least a few years and often twenty 
or more years. Cases in which a carcinoma develops in 
the scar of a wound for the removal of a malignant growth 
should not be considered in this class, as such cases are 
more probably the result of implantation of cancer cells 
at the time of the operation. 

There are at least four theories or explanations of the 
development of a carcinoma in a scar. 

The first theory is that in the healing of the wound 
that caused the scar, some of the hair or sebaceous follicles 
of the skin were covered over by epithelium in the cicatri- 
zation of the wound and their ducts obstructed. This 
prevented the discharge of their secretions, which then 
acted as an irritant and produced the carcinoma. Accord- 
ing to this explanation, the carcinoma originates in the 
gland epithelium and then breaks down forming an 
ulceration. 

Another theory which is advanced by Thielhaber is 
that in the lesion that produced the scar there was a 
destruction of tissues and a definite interference with 
the blood supply and the nutrition of the parts. This 
condition closely resembles the tissues of advanced age, 
in which carcinoma is disposed to occur. It is stated 
that as a result of this condition there is an overgrowth 
of the cellular structure, while the intercellular and 
fibrous tissue atrophies. This overgrowth of the cells 
results in the carcinoma. 

Another theory is that the scar acts as a foreign body 
and irritates the surrounding tissues. This cicatrix, 
situated as it is in the tissue of different elasticity and 



58 PRECANCEROUS LESIONS 

resiliency, does not yield freely, and as a result the tissues 
are irritated by it. According to this explanation the 
scar itself is the irritant. 

Still another theory is that the scar is irritated or 
injured, and a carcinoma is started in the cicatrix as 
in any other place, excepting that the scar is abnormal 
and more easily injured, and therefore a cancer may be 
developed in it more easily than in normal tissue. There 
are various examples of carcinoma developing in a scar 
that has been directly irritated or repeatedly injured. 
This is most frequently seen in the scars resulting from 
burns. The scar from a burn is often thin and delicate 
and easily injured, particularly if it is in an exposed place. 
A slight injury may cause a small ulcer which heals slowly 
and often breaks out again after it has healed. If a 
cicatrix resulting from a burn, as on the flexor surface of 
an extremity and its contraction, has limited full extension 
it may be repeatedly injured by the ordinary movements 
of the arm or leg. If a carcinoma develops in a scar under 
any of these circumstances, it is probable that it was 
caused by irritation or repeated injuries. 

None of these theories really explains the cause of the 
development of a carcinoma in a scar. They all describe 
certain phenomena that occur in connection with scars 
and carcinomata, but fail in demonstrating the real 
cause of the development of one in the other. There is 
no doubt that a carcinoma sometimes develops in a scar. 
Neither is there any doubt that the scar had a defi- 
nite influence in the development of the malignant 
growth. 

When the enormous number of small scars of various 
kinds and the infrequency of scar cancers are considered, 
it must be appreciated that the influence of a scar in the 
development of a malignant growth is small. It is pos- 
sible, however, that a better knowledge of the etiology of 
malignant growths will show the influence of scar tissue. 
It has been shown that a previous history of acute mastitis 
is common in cases of carcinoma of the breast, and it is 



NEVI— WARTS 59 

probable that the scar tissue in the breast is the active 
factor. A better knowledge of the pathology of malignant 
growths may show the way in which scar tissue affects 
the malignant growths. 

Benign Growths as Precancerous Lesions. — The change 
of a benign into a malignant tumor, that is, the so-called 
malignant transformation of a benign tumor, is a subject 
of great practical importance in the therapy of tumors. 
Tumor tissues undergo various changes in the same way 
that normal tissue does. They may become infected, 
necrotic, calcareous, etc. There is definite laboratory 
and clinical proof that benign tumors may change into 
malignant growths. For example, an adenoma may change 
into a carcinoma or a fibromyoma may become a sarcoma. 
There is also ample clinical proof that these changes are 
very rare. 

If these changes were frequent the indication would be 
to remove all benign tumors in order to avoid the malignant 
change. This is sometimes the correct indication. More 
frequently benign tumors are removed because it is not 
possible to make a positive diagnosis, and to know that 
they are benign except by removal and microscopic 
examination. 

Certain varieties of tumors show greater tendencies 
to become malignant than others. For example, a lipoma 
rarely changes to a malignant growth. An adenoma 
probably does more frequently. 

The location of the tumor also influences the change 
in the malignancy of the growth. For example, a papilloma 
of the urinary bladder shows marked tendencies to become 
malignant. This tendency is so great that some observers 
believe that ultimately, if not removed, all such growths 
Would become malignant. 

Nevi, Warts, Etc. Some warts are congenital, others 
appear during Inter years. During childhood, warts on 
the fingers arise without known cause and disappear 
as mysteriously. The warts and nevi that arc con- 
genital usually persist, and these, together with those 



60 PRECANCEROUS LESIONS 

that appear later and persist, are of significance as possible 
precancerous lesions. 

Keen, in 1904, reported 25 cases, of which 12 were 
from his own practice, of malignant change occurring in 
warts and moles. The fact that 12 cases of this kind 
occurred in the experience of one man, even though 
his experience was a large one, shows the importance 
of warts and nevi in their relation to cancer. In a 
number of these cases death resulted from recurrences or 
metastases after the operation. 

The history of these cases is as follows: The wart 
or mole after existing as a benign tumor for a long period, 
that is, in some cases for forty years or more, shows signs 
of irritation or inflammation. At first the change is very 
slight, merely suggesting an inflammation about the wart 
or nevus. Later there may be ulceration and metastases 
in the skin, neighboring lymphatic glands, and distant 
organs. 

In a number of cases, irritation or traumatism seemed 
to be the exciting cause. This irritation may be from 
clothing, combing of hair, occupation, and, in a number 
of cases, insufficient attempts at removal. 

Usually the malignant change is to an epithelioma, 
sometimes to sarcoma. 

Wilson and Kalteyer collected 50 cases of multiple 
sarcomata of the skin, and arranged them in three groups: 

1. Multiple melanotic sarcomata ... 26 per cent. 

2. Multiple non-pigmented sarcomata 26 " 

3. Multiple pigmented, hemorrhagic sarco- 



Of these cases of multiple sarcomata of the skin, in 
69 per cent, the primary growth had its origin in a nevus 
or mole. Eves found in 33 cases of melanosarcoma, 26 
cases began in pigmented moles. 

These cases are sufficient to show that benign warts 
and nevi are sources of danger. 

Keen advises the removal of warts and moles to avoid 
the possibility of malignant change. This obviously 



UTERINE FIBROMATA 61 

would not apply to those cases in which there is a large 
number of moles scattered over the whole body. Any 
wart or nevus that is located in a place where it is exposed 
to constant or frequent irritation should certainly be 
removed. This would apply to all warts on the hands or 
feet, to those that may be irritated by clothing, such as 
collar, hat band, corset, etc., or by combing the hair or 
shaving, etc. Every wart or nevus should be removed 
at once if any sign of irritation develops. 

After multiple malignant tumors have developed in 
the skin, little can be gained by any attempt to remove 
them. 

Uterine Fibromata. — The question of uterine fibromata 
becoming sarcomata has long been a subject of interest 
to gynecologists. It is estimated that 20 per cent, of all 
women develop uterine fibromyomata, though they 
all do not give symptoms. It is known that uterine 
sarcomata are also frequent. Different laboratories 
estimate that from 2 to 8 per cent, of cases of supposed 
fibromyomata of the uterus that are removed, show 
elements of sarcomata. This indicates that fibromyomata 
and sarcomata are both frequent tumors of the uterus, 
but it does not demonstrate that the sarcoma is a later 
development of the fibroma. It must not be assumed, 
therefore, when sarcomatous tissue is found in a growth 
largely composed of fibrous tissue that it indicates that 
the benign fibromyoma has changed to a malignant 
sarcoma. 

There are cases in which a fibromyoma of the uterus 
is involved by the extension to it of a sarcoma of the 
endometrium. Such a case, however, should not be 
considered as a change from a benign to a malignant 
growth. 

There are reported in the literature well-authenticated 
cases of fibromyomata of the uterus undergoing sarco- 
matous transformation. These cases arc very infrequent. 
They are so infrequent that some pathologists of wide 
experience state that they have never seen a case of fibro- 



62 PRECANCEROUS LESIONS 

myoma of the uterus changing to a sarcoma. If a sar- 
coma is found it is probable that the sarcoma existed as 
such from the start. 

A carcinoma has been described as developing in 
fibromyoma of the uterus, but this is probably less 
frequent than the sarcomatous change. Epithelial 
elements are described as being found in the interior 
of uterine fibromyomata, and in these a carcinoma may 
develop. 

There are cases in which a carcinoma develops in the 
mucous membrane of a uterus containing a fibrous 
polyp as a result, it is believed by some observers, of the 
irritation caused by the polyp. Theoretically the con- 
tractions of the uterus in attempting to expel the polyp 
might produce irritation or repeated injuries that are 
believed to cause the development of the carcinoma. 
If the carcinoma develops in the polyp it would be an 
example of a benign tumor becoming malignant. If it 
developed in the uterine mucous membrane it would 
not be in the same class, but would illustrate the develop- 
ment of a malignant growth as a result of irritation by a 
benign growth. 

Polypi of the G astro-intestinal Tract. — An excellent 
example of a benign growth becoming malignant is seen 
in the benign polypi of the gastro-intestinal tract changing 
to carcinomata. According to Wolff, attention was first 
extensively directed to this change by Brissaud in 1885. 

Polypi in the stomach and intestines are of common 
occurrence and are seen in young patients. They may 
be the outcome of embryonal defects in the mucous 
membrane or the result of inflammation or other cause. 
They are more common in the rectum and colon than 
higher in the gastro-intestinal canal, and are frequently 
multiple. These tumors may exist for a long period 
before any malignant change occurs. 

The cause of the change is not clear. The tissue of 
which the polyp is composed is not normal. It is claimed 
by some that it is covered by modified epithelium, which 
is predisposed to a cancerous change. 



ADENOMATA 63 

There are two common factors, chronic irritation, 
and chronic inflammation, which are probably important 
influences in causing this change. The chronic irritation 
is partly from the intestinal contents and partly from 
the peristaltic action of the intestines. The chronic 
inflammation is partly from partial obstruction of the 
intestines, with the retention of feces, and partly from 
the chronic irritation. 

Adenomata. — These tumors, though benign, have a def- 
inite histological relationship to carcinomata. As a rule 
they can be definitely distinguished from each other, 
but in some cases it is difficult or impossible to place a 
tumor absolutely in one or the other group. It is undoubt- 
edly true that some cases of adenoma change and become 
malignant. Clinically this is certainly of frequent occur- 
rence. The doubtful tumors, that is, the tumors that are 
difficult for the pathologist to place definitely in the 
benign or malignant class from the microscopic examina- 
tions, are usually of recent development. 

In general, regarding the relationship of benign to 
malignant growths, it must be accepted that benign 
tumors show a greater disposition to become malignant 
than normal tissue. 

It is true also in proportion to the total number of 
benign tumors that these changes are rare; that is, the 
type of a tumor usually remains the same and does not 
change. 

Furthermore, these changes, when they occur, are often 
more apparent than real; that is, the malignant process 
starts in the tissues in the immediate vicinity of the 
benign growth, possibly due to irritation by the benign 
tumor which is involved only by extension. 

The cause of the malignant change in a benign tumor 
is obscure, (snail v the same agents that seem to have an 
influence in the development of the cancer elsewhere — 
that is, age, chronic inflammation, injury, irritation, etc. — 
arc probably important factors in causing the malignant 
change. 



CHAPTER III. 
CONTAGIOUSNESS OF CANCER. 

Among the ancient writers, cancer was considered to 
be contagious; that is, that the disease could be trans- 
mitted from man to man, also from man to animal, and 
from animal to man. It was believed that the contagion 
was transmitted through the air by the cancer vapors, 
or by the cancer juice, or by the cancer cells, or by cancer 
parasites. 

Wolff, from the literature of several centuries ago, 
gives examples of cases that were supposed to have 
developed from infection transmitted in these various 
ways. For example, the vapor from an ulcerating carcin- 
oma of the breast was claimed to have caused cancer. 
A woman was reported to have developed a cancer of the 
neck directly after drinking water that had been con- 
taminated by "cancer juice" from dressings from a 
carcinoma. A case is given of a girl who developed a 
cancer twenty years after drinking water containing 
"cancer juice." To illustrate the transmission of cancer 
from man to animal, there is quoted the case of a dog 
licking the cancerous lip of his master and later develop- 
ing cancer. Also of a dog developing a cancer of the 
stomach after eating cancerous tissue. 

In more recent literature, to illustrate the contagious- 
ness of cancer through the medium of cancer cells, cases 
of "cancer a deux," that is, cases of cancer occurring 
in two people living in close relationship as, for example, 
husband and wife, are quoted. A number of cases are 
reported of cancer of the penis and of the uterus occurring 
in husbands and wives. 



CONTAGIOUSNESS OF CANCER 65 

These cases well illustrate the opinions that have held 
during different periods of the contagiousness of cancer. 
First, that it might be transmitted through the air, 
then that it might be transmitted through the air only 
after the growth had become ulcerated, later that contact, 
especially with mucous membrane, was necessary, and 
finally, that repeated contact and probable introduction 
of cancer cells into microscopic injuries, was necessary 
in order to transmit cancer. 

The evidence of the contagiousness of cancer that is 
contained in such cases in the literature is further sup- 
ported by two facts in regard to cancer that are universally 
known. Certain forms of cancer in some animals can 
beyond question be transmitted from one animal to 
another of the same species. This is the case with certain 
cancers in mice. If a mouse cancer can be transmitted 
from one mouse to another it is a strong argument that 
some cancers, and of course there are many varieties of 
cancer, can be transmitted from one human to another. 
The second fact is one concerning which there is no doubt; 
in fact, one that is included in most definitions of cancer. 
It is that a cancer can be transmitted from one place to 
many different parts of the same individual. This can 
happen not only through metastases in the natural 
course of the growth, but also by implantation in the 
surgical wound. 

It is not strange, with the evidence of the cases reported, 
supported by other known facts in regard to cancer, that 
its possible contagiousness is constantly before the medical 
profession, and always in the minds of the laity. 

As a matter of fact, however, the cases reported are 
either unreliable or the condition can better be explained 
in other ways, and practically cancer is not considered 
contagious. 

The possibility of contagion through the atmosphere 
by cancer vapors is too far removed from the ideas of 
modern medicine to be further considered. 

Dogs have been fed on cancerous tissue without their 
5 



66 CONTAGIOUSNESS OF CANCER 

developing cancer. This would indicate that cancer 
cannot experimentally be transmitted from man to dog, 
either through contact of mucous membrane with cancer 
or by the ingestion of cancer juices. 

It is not difficult to disprove the evidence that cancer is 
contagious, that is given when cancer develops in one 
member of a family shortly after a similar one in another 
member. This is true even when it concerns a cancer 
of the penis and a cancer of the cervix uteri or some 
part of the vaginal tract. The evidence of the contagious- 
ness of cancer furnished by cases of this kind is of limited 
value. 

Carcinoma of the uterus is a common disease; there are 
thousands of cases every year. Even though carcinoma 
of the penis is relatively rare, it must be accepted that by 
chance occasionally a carcinoma of the penis and of the 
uterus should occur in a husband and wife. This com- 
bination must be infrequent, because such cases are of 
such peculiar interest that they would be found more often 
in the general literature if of common occurrence. 

The more practical and stronger evidence against the 
contagiousness of cancer is that cases that have apparently 
developed as the result of contagion are not seen by men 
of wide experience. Cancer is a very common disease, 
and there are an enormous number of cases in the ulcera- 
tive stage, the stage in which the greatest contagiousness 
would be expected, which are being cared for by members 
of the family of the patient, that is, by people not specially 
trained to avoid infection. If cancer were contagious, 
evidence of it would be found in some of the numerous 
families. 

Further practical evidence that cancer is not contagious 
is seen in surgical work. Throughout the world in every 
civilized country, surgeons are daily operating upon 
thousands of cases of cancer. Surgeons, through small 
cuts and needle pricks, received during operation become 
infected by syphilis, pyogenic organisms, etc., but they 
do not become infected with cancer. If cancer were 



RECURRENCES 67 

contagious, there would surely be examples in this vast 
amount of possible material. 

It can be assumed, therefore, that in the sense of 
being transmitted from one person to another, under 
ordinary conditions, cancer is not contagious. 

Recurrences. — By this term is meant the reappearance 
of the disease after its removal in the immediate vicinity 
of the original growth. Ancient writers believed that a 
recurrence was, as its name implies, a return of the cancer 
after it had been completely removed. The present 
belief, and undoubtedly the correct one, is that the original 
malignant growth was not entirely removed. In other 
words, the recurrence is a definite and direct continuation 
of the original growth, of which at least a microscopic 
part was not removed. 

The recurrence is most frequently in the scar or in the 
tissue that was nearest to the original growth. At other 
times it is near the scar but separated from it by an interval 
of normal tissue. 

There are three ways by which cancer cells are left in 
the tissues and recurrences result : 

1. Cancer cells may exist previous to the operation, 
outside the area of tissue removed at the operation. 

2. Cancer cells during an examination or the operation 
may be mechanically forced into the area outside of the 
tissue originally involved. 

3. By implantation, that is, cancer cells from the 
primary growth may be implanted on the surface of the 
operative wound and be the starting of a new growth. 

The knowledge and consideration of these three reasons 
why recurrences of cancer take place are of the greatest 
practical value and modify the modern treatment and 
operative technique of cancer. 

1. In the description of metastases, and also in the 
chapter on Carcinoma of the Breast, the presence of 
cancer cells in the lymphatic vessels, and also to a less 
extent in the veins and tissues, has been described. All 
modern operations lor cancer are based on the knowledge 



68 CONTAGIOUSNESS OF CANCER 

that to remove all of it, not only all the tissue that macro- 
scopically is diseased must be removed, but also a wide 
area of tissue that is apparently normal, otherwise tissue 
containing the microscopic cancer cells will be left and a 
recurrence will occur. In doing this, particular attention 
is given to the tissues that are known to contain cancer 
cells most frequently. The result of this is that in the 
modern operations for cancer the organ or parts in which 
it is located is removed as widely as the anatomical 
relations will allow. This is well illustrated in the present 
operation for cancer of the breast. Not only is the entire 
breast removed with the cancer but also a wide area of 
skin and a wider area of the deep fascia, the pectoral 
muscles and the axillary lymphatic glands. Each step 
in the development of the operation has made it more 
extensive and also increased the percentage of permanent 
cures. 

2. The mechanical displacement of cancer cells by 
manipulation is an undoubted cause of some recurrences 
following operation, and is a possibility that should be 
more generally appreciated both by the physician and 
the patient. There is no doubt that through ignorance 
the spread of cancer cells is favored by improper handling 
of the growth. 

Under proper circumstances, rubbing or massage 
of a swelling such as may result from injury or inflamma- 
tion is the proper treatment. This knowledge is fre- 
quently used by the patient without consulting a physician. 
When massage is used on a swelling which may be a cancer, 
as, for example, a swelling in the breast, it is associated 
with great danger and doubtless the favorable outcome 
of many operations for cancer has been made impossible 
by this improper treatment. 

The manipulation of a malignant growth by a physician 
in an examination is associated with the same risk of 
displacing cancer cells as any other manipulation. For 
this reason, any examination of a possible cancer should 
be associated with the greatest gentleness, and repeated 



IMPLANTATION RECURRENCES 69 

examinations, unless necessary, should be avoided. The 
seriousness of many operations for cancer and the desire 
of both patient and surgeon for consultation may require 
more than a single examination, but the danger should be 
remembered and the smallest amount of manipulation 
possible should be used. 

To avoid the mechanical risk of scattering cancer 
cells, cancerous tissue should not unnecessarily be cut 
into either during or before an operation. There are 
some uncertain and doubtful cases that cannot be diag- 
nosed with sufficient certainty to warrant an extensive 
operation without a microscopic examination of a piece 
of the tissue. The common custom, therefore, of removing 
such pieces of tissue for immediate microscopic examina- 
tion of a frozen section of it is necessary in some cases. 
The danger of scattering cancer cells can be lessened, in 
some cases, as in carcinoma of the cervix uteri, by remov- 
ing the piece of tissue for examination with the cautery. 
In other cases, as in some tumors of the breast, the danger 
can be lessened, if not entirely avoided, by removing the 
entire tumor with some additional tissue apparently 
normal about it instead of incising into the tumor itself. 
Some reliable observers state that the statistics of opera- 
tions for cancer of the breast that have not had a prelimi- 
nary excision of a piece of it for microscopic examination 
are more favorable than those that have had a piece 
excised. 

3. Implantation Recurrences. — While cancer cannot be 
transferred from one person to another, it can be trans- 
ferred from one to another part of the same individual. 
One example of this is the formation of metastases. 
Another less frequent example of the transference of 
cancer from one part of the body to another is that 
which occurs as the result of direct contact of the cancer 
or the cancer cells with a wound. The danger of such 
infection is one reason for not allowing a sloughing cancer 
or its cut surface to come in contact with the wound of 
the operation. The possibility of transplanting cancer 



70 CONTAGIOUSNESS OF CANCER 

in this way was long questioned, but the cases seen and 
reported by different observers are too common and 
definite to leave any doubt in regard to it. The most 
convincing cases are those in which a cancer develops 
in the scar of an abdominal wound within a few months 
after the removal of a malignant growth from the abdomen. 

The anatomical relations of the scar to the original 
growth excludes the possibility that the growth in the 
scar is either a local recurrence or a metastasis. It can 
naturally be explained only as an implantation. There 
can be little doubt that such a growth in the abdominal 
wound is the direct result of cancer cells being deposited 
on the wound surface at the time of the operation. 

Another example of the recurrence occurring in a wound 
about which there can be no question is the growth which 
occurs along the wound made by a trocar in tapping a 
malignant papilloma of the ovary or the abdomen in a 
similar case in which the peritoneum has been secondarily 
involved. The conditions are all extremely favorable for 
the formation of such a secondary growth. The cancer 
cells or the pieces of cancerous tissues are sterile, and are 
deposited along the course of the wound that is also 
sterile, and which is at once closed so that no outside 
influence may interfere with the growth of the malignant 
cells in their new location. There are a number of cases 
of this kind reported in the literature. Cullen reports 
such a case. A papillary cyst of the ovary was tapped. 
Several weeks later an exploratory laparotomy was per- 
formed, and in the abdominal wall beneath the skin and 
along the track of the trocar were found multiple growths, 
which had the histological characteristics of the ovarian 
growth. 

Implantations in the vagina during operations for 
carcinoma of the uterus may occur in two places. In 
performing a vaginal hysterectomy for carcinoma of the 
uterus, it is necessary in the cases with narrow vaginas 
to make an incision on one or both sides of the vulva to 
widen the orifice. A number of cases have been reported 



TIME OF RECURRENCE 71 

in which carcinoma has developed in the incisions. It is 
obvious that such cases can only be the result of implanta- 
tion of cancer cells during the operation, as neither local 
recurrences nor metastases would be likely to occur in 
such places. 

The second place in which cancer cells are undoubtedly 
implanted during the operation for cancer of the uterus 
is in the wound in the top of the vagina. With many 
cases of carcinoma of the cervix uteri which are considered 
operable, it is technically impossible to keep the cancer 
surface always away from the cut edge of the vaginal 
wound. To avoid the implantation that might therefore 
otherwise occur, it is usual in these cases for the surgeon 
to destroy as much as possible of the cancer with the 
cautery before any incision is made. It is best also to 
make the incision through the vaginal wall with the 
cautery. It is well known that the recurrence following 
an operation for carcinoma of the uterus is most frequently 
in the vaginal scar. It is not possible to state that 
this is due to implantation of cancer cells at the time of 
the operation with the same certainty as when it occurs 
in the lower vulva incisions. The local recurrence may 
be due to local extension of cancer tissue that existed 
previous to the operation and beyond the parts removed. 
It is probable, however, when the recurrence is in the 
top of the vagina and not in the bases of the broad liga- 
ment at the sides, that it is due to the implantation of 
cancer cells at the time of the operation. Certainly it 
is of the greatest importance that the possibility of such 
implantation is considered in all operations for cancer of 
the uterus. 

Time of Recurrence. — It is probable if cancer cells 
remain in the tissues after an operation, that they 
continue to proliferate; but as the term "recurrence," 
as it is commonly and loosely used, really means reappear- 
ance, the time of recurrence really means the time at 
which the recurrence can be demonstrated. It is becom- 
ing more and more evident that it is not possible to give 



72 CONTAGIOUSNESS OF CANCER 

the late limits at which a recurrence may occur. The 
general statement that the longer the period that has 
elapsed since the operation the less likely is the growth to 
recur, is more nearly true than any other that can be made. 
Formerly three years was arbitrarily taken as the time 
which must elapse before a cancer case could be considered 
"cured." It is necessary to have some fixed limit for 
statistical purposes, and as it was found that there were 
numerous recurrences after the three-year period, the 
time was lengthened to five years. It is now generally 
accepted in all countries that five years must have passed 
since an operation for cancer before the case can be 
reported as "cured," and that at that time the case can 
be so considered, though later recurrences are known to 
occur. 

As a rule, recurrences take place early, but statistics 
in regard to the time are indefinite and are influenced 
by the location and by the extent of the primary growth. 
If the primary tumor was located in an organ that is 
easily accessible to examination, a recurrence as well as 
the primary tumor would be recognized early. In a more 
inaccessible organ a recurrence could not be demonstrated 
until it had reached a more advanced stage. The period 
at which a recurrence takes place also depends on the 
extent and malignancy of the primary tumor. A series 
of advanced cases will give an early list of recurrences. 

Late Recurrences. — The usual rule that if any cancer 
cells remain in the tissues that they begin at once to 
proliferate and grow is by no means absolute. Beyond 
doubt, as is discussed in the section on spontaneous cures, 
not all cancer cells remaining in the tissues continue to 
grow. There is definite clinical evidence that, though 
diseased tissue was present and not removed at the time 
of the operation for cancer, yet the case remains per- 
manently cured. In other cases the growth of the cancer 
cells are held in check for a time. If, for example, follow- 
ing an operation for cancer of the breast, a small nodule 
appears only at the end of three or four years, it must be 



LATE RECURRENCES 73 

accepted that it has not been growing during this entire 
period or else it would have been palpable at an earlier time. 

By late recurrences are usually meant those that occur 
five or more years after the operation for the removal 
of the primary tumor. There are numerous cases in the 
literature of recurrences in the immediate vicinity of the 
wound at the end of ten, fifteen and twenty years. There 
are two possibilities in regard to these late recurrences: 
By some, they are considered to be not recurrences but 
second primary growths which developed in the scar or 
in the neighboring tissue and had no direct relationship 
with the original tumor. The similarity of the histological 
structure of the primary growth and the late recurrence 
would be against this explanation for all cases. 

Another explanation is that the cancer cells, though 
remaining alive, become encysted or walled in by the 
tissues in the same way that any foreign body may be. 
After a period of years, as a result of traumatism, of 
disturbed metabolism or of causes with which we are not 
familiar, these cells become freed, begin to grow and 
produce the late recurrence. 

The conditions that control all recurrences are closely 
related to the specific cause or causes of cancer. Until 
more is known about these causes of cancer in general, 
it is probable that the real reasons for the late recurrences 
will remain concealed. 

It must be remembered that these late recurrences 
are rare and constitute a very small percentage of the 
cases. It is probable that the chances of a recurrence 
after the period of five years are less than if the original 
tumor had not developed and the organ in which it was 
situated had not been removed. There is always a 
risk that carcinoma may develop in an organ. The 
woman, for example, whose uterus or breast has been 
removed for carcinoma probably runs less risk of a recur- 
rence after a period of five years than a woman whose 
breast or uterus has not been removed runs of developing 
a primary tumor in one of these organs. 



74 CONTAGIOUSNESS OF CANCER 



METASTASES. 

A metastasis is the spread of a disease from one part 
of the body to other organs or structures. For example, 
there may be an original or primary lesion in the breast, 
and from this primary lesion in the breast other organs, 
such as the liver or spleen, may be involved by secondary 
growths. These secondary growths are spoken of as 
metastases. The most frequent use of the word is in 
regard to malignant disease. While the word metastases 
is used most frequently in regard to malignant conditions, 
it is not its only use. In pyemia, for example, the original 
lesion or focus may be in the uterus, and from that original 
lesion secondary abscesses may develop in other organs, 
such as the liver or parotid gland. These second ary 
abscesses may be and frequently are spoken of as " metas- 
tatic abscesses." 

Care must be taken not to confuse the term metastasis 
with recurrence. A metastasis is the appearance of the 
disease in a distant part, and in many cases is the natural 
way by which the growth progresses. A recurrence is a 
return or, better, the reappearance of a malignant process 
in the immediate vicinity of the primary growth, and the 
term carries with it the implication that an attempt was 
made to remove the original growth. "While the term 
recurrence is in frequent usage and will remain so, it is 
not strictly correct. Strictly, the word implies that the 
original disease was removed and that later it returned or 
recurred. As a matter of fact it was not entirely removed. 
If it were entirely removed it would not come back, and 
the fact that there is a recurrence proves that a part of 
the disease, possibly microscopic in size, was not removed. 
A metastases has no reference to an operation or other 
therapeutic measure, it is a part of the natural progress of 
the disease. 

Ancient writers recognized that malignant growths 
were followed or accompanied by metastases in distant 
organs, but it long remained obscure how the}' occurred. 



METASTASES 75 

At one time it was believed that the metastatic growths 
as well as the primary lesion were the result of a general 
diathesis, and that there existed in the body certain 
"humors" which circulated in the blood and caused the 
cancerous growths. Later it was recognized that the 
growths in various parts of the body came from a single 
primary tumor and it was then believed that the primary 
tumor produced the "humor" in the form of a "cancer 
juice" which by osmosis or in some other way gained 
access to the blood, circulated to various parts of the 
body and produced the secondary growths. 

It is now known that cancer cells from the primary 
tumor are the cause of the metastatic growths. These 
cells are transferred from the primary tumor to distant 
parts chiefly in three ways : 

1. Lymphatic system. 

2. Venous system. 

3. Arterial system. 

In general the importance of the systems in spreading 
cancer throughout the body is in the order named. It is 
generally believed that carcinomata spread mostly through 
the lymphatics and sarcomata through the bloodvessels. 
This idea is doubted by others who claim that the sarcoma 
cells enter the lymphatic system with the same frequency 
as the carcinoma cells, but on account of their size and 
shape they are not filtered out by the lymphatic glands 
and so pass on to the vascular system; that is, the sar- 
coma cells reach the vascular system more frequently 
than the carcinoma cells, but they do so indirectly through 
the lymphatic system. 

The Lymphatic System. — Cancer cells from the primary 
growth may escape into the lymphatic vessels. These 
cells may become lodged at any point in the lymphatic 
vessel, begin to proliferate and produce a secondary 
growth in the vicinity of the primary tumor. The 
lymphatic vessel for a considerable distance may be 
filled with cancer cells, partly from the primary growth 
and partly by the proliferation, forming a definite chair 



76 CONTAGIOUSNESS OF CANCER 

of carcinomatous nodules, the so-called lymphangitis 
carcinomatosa. 

Instead of being stopped in the lymphatic vessel, the 
cancer cells may be carried by the lymph stream to the 
lymphatic gland. The lymphatic gland acts as a filter, 
and for a time at least, the further spread of the disease 
in this direction is checked. In the lymphatic gland, the 
cancer cells may be destroyed or they may proliferate and 
produce a secondary growth or metastasis in the gland. 

The metastases in the neighboring lymphatic glands 
are usually the first secondary growths that are formed. 
Histologically the secondary growth in the gland corre- 
sponds to the primary tumor. The gland becomes enlarged 
and hard and gradually takes on the same characteristics 
as if it were a primary tumor. First one and later a 
number of glands of a set or chain are involved. 

The regularity with which the lymph nodes are involved 
and enlarged, at some stage of carcinoma of an organ, 
makes the enlargement of these glands a valuable diag- 
nostic sign. For each organ there is a definite set of 
glands in which a metastatic growth may first be expected, 
and the presence or absence of the enlargement of such 
glands is one of the best indications of the extent and 
duration of the growth. If there is no enlargement of the 
glands, it is probable that the growth is of short duration, 
of limited extent, and more favorable for operation. 
The enlargement of the glands does not necessarily indicate 
the opposite, because it may be due to other causes than a 
cancerous involvement on to an early metastasis. 

In some cases, the first chain of lymphatic glands is not 
involved, but the second is. For example, from a car- 
cinoma of the hand the glands of the axilla may be involved 
before those at the elbow. It is possible in such a case 
that the cancer cells pass through the first set of glands and 
are checked by the second. The more probable explana- 
tion is that the lymphatic vessels, sometimes in an atypical 
manner, carry the cancer cells around the first set of 
glands directly to the second chain. 



METASTASES 77 

The lymphatic glands can check the spread of a malig- 
nant disease only for a time. Cancer cells from a secondary 
growth can gain access to the distal lymphatic vessels in 
the same manner as from the primary tumor. After the 
involvement of one or more sets or chains of lymphatic 
glands, the last barrier is passed and the cancer cells enter 
the general vascular system through the thoracic or other 
lymphatic channel. After the vascular system has been 
entered the cancer cells can be carried to any part of the 
body. 

Venous System. — Cancer cells may enter the venous 
system indirectly by passing first into the lymphatic 
system, as has been described, or may enter it directly 
by the involvement of the wall of the vein itself. As 
the cancer grows the wall of the vein may be invaded in 
the same way as other structures, and when the intima 
is reached and eroded, the cancer is in direct contact 
with the blood current. In this way cancer cells may be 
spread throughout the body through the vascular system. 
By the continued growth of the cancer, the lumen of the 
vein may be filled with the cancer cells to such an extent 
that it is entirely obstructed. 

As a rule the metastases from the direct involvement 
of the vein come at a later stage than those through the 
lymphatic system. They may, however, occur earlier. 
Usually the smaller veins are the only ones involved, 
but in some cases the largest veins are directly affected. 
For example, Kantorowicz describes a case of carcinoma 
of the breast in which the subclavian vein was directly 
involved. It has been noticed that when the large veins 
are directly involved, the metastases are very numerous 
even in organs not frequently involved, and the course 
of the disease from then on is a rapid one. 

Some cases have been reported in which the veins 
bave been involved without metastases. These cases are 
infrequent and probably occur shortly before death, and 
there has not been sufficient time for metastases to be 
formed after the growth has invaded the vein. 



78 CONTAGIOUSNESS OF CANCER 

Arterial System. — Metastases through the arteries are 
less frequent than following invasion of the veins. The 
walls of the arteries are thicker and more resistant to the 
invasion of the growth. When the arteries are invaded, 
the cancer cells are carried toward the periphery and 
would be caught in the capillaries. There are cases on 
record in which large arteries, even the aorta, have been 
invaded in the progress of a malignant growth and a fatal 
hemorrhage the result. These cases are rare. 

Retrograde Metastases. — Metastases sometimes occur in 
locations that are explained by accepting the theory that 
they have formed against the flow in the lymph or venous 
system. They are called retrograde metastases. It has 
been demonstrated, clinically and experimentally, that 
there is a reversal of the current in the lymphatic vessels 
or in the veins, and that it flows in a direction opposite 
to the normal. It is conceivable, that in the abnormal 
conditions produced by a malignant growth, that this 
may sometimes happen in small vessels in the immediate 
vicinity of the growth. It is doubtful if it does to any 
great extent, particularly at a distance from the growth. 
The more usually accepted theory is that the malignant 
tumor grows rapidly along the lymphatic vessels or the 
veins. The lumen of the vessel may be occluded by the 
proliferation of the cancer cells, so that the natural flow 
in the vessels is entirely stopped. Under these conditions 
the cancer may grow more rapidly along or in the vessels 
than in the surrounding tissue, and at some point a 
lymphatic vessel or vein is reached in which the current 
runs normally in the opposite direction, and in which the 
cancer cells are carried to the parts supplied by it. 

Peritoneal Metastases. — When cancer cells reach the peri- 
toneal cavity either from a cancer of one of the abdominal 
viscera extending through the peritoneal layer, or from 
any organ of the body through the lymphatic system, 
metastases may be formed in ways different from those 
described. 

Cancer cells or pieces of malignant tissue may be de- 



EXTENSION BY CONTACT OR IMPLANTATION 79 

tached from the primary growth in the peritoneal cavity 
and be carried by gravity from the upper to the lower 
part of the abdominal cavity and, becoming engrafted, 
form metastases there. Metastases on the anterior 
wall of the rectum occur from a primary carcinoma of 
the stomach and is a sign that the primary growth has 
penetrated the peritoneal layer and that the case is 
inoperable. Metastases in the ovaries are also seen from 
a carcinoma of the stomach. In both these instances 
the cancer cells are believed to have been carried by 
gravity from the stomach to the pelvis. 

The movement of the abdominal viscera is responsible 
for some peritoneal metastases. In cases of ovarian 
papillomata the entire peritoneal cavity may be covered 
by small metastases. It is difficult to explain these 
numerous metastases on the peritoneum in any way 
except by the spread of cancer cells, by the movements 
of the abdominal viscera, or by the natural movement of 
the peritonea] fluid in the abdominal cavity. Some of the 
metastases that appear to be in the peritoneal cavity 
are really beneath the peritoneum. These must have 
originated in other ways, that is, through the lymphatic 
or vascular systems. 

In the thoracic cavity metastases may occur in the 
same wax' as in the peritoneal cavity. 

EXTENSION BY CONTACT OR IMPLANTATION. 

These are sometimes spoken of as implantation metas- 
tases. There are numerous cases in the literature that 
confirm the belief that if a cancer remains constantly in 
contact with tissue, cancer cells will be implanted and a 
cancerous growth formed in it similar, histologically, to the 
primary growth. That this secondary growth is not 
due to the irritation is proved by the similar histological 
structure of the two growths. 

Implantation on Serous Membranes. — After a malignant 
papilloma of the ovary lias perforated the cyst wall, the 



80 CONTAGIOUSNESS OF CANCER 

peritoneum is soon covered by small papillomatous out- 
growths similar, histologically, to the primary tumor. 
The majority of these small papillomata are the result 
of papillomatous cells being carried by the lymph currents 
and the movement of the abdominal viscera throughout 
the peritoneal cavity. Undoubtedly some of these 
secondary growths result through adhesions of the 
primary growth with surrounding structures and the 
direct extension of the malignant process through these 
organized adhesions. Neither of these methods correctly 
illustrate contact infection. There is no doubt, however, 
that direct contact infection does occur in the abdominal 
cavity. While there may be some question regarding 
the possibility of contact infection between a septic, 
sloughing carcinoma and normal mucous membrane as, 
for example, between a carcinoma of the cervix uteri 
and the vagina, there can be no doubt about it, in regard 
to a papilloma of the ovary in the peritoneal cavity. In 
this case the malignant growth is not septic and the 
peritoneum and omentum readily become attached to a 
growth or other abnormal mass in the abdominal cavity. 
If it is accepted that free cancer cells in the peritoneal 
cavity can become attached to the peritoneum and form 
secondary growths, it is easy to believe that cancer cells 
that are still a part of the primary growth and are still 
nourished by it may form a secondary growth by contact. 

There can be little or no doubt that implantation of 
cancer by contact with serous membrane takes place not 
only in the peritoneal but also in the thoracic cavity. 

Implantation on Mucous Membrane. — The most frequent 
example that is seen of this occurs in the vagina from a 
carcinoma of the cervix uteri. It is doubtful if cancer 
cells can be implanted and grow on normal mucous 
membrane. It is more probable that the hard, everted 
edges of the malignant growth in the cervix uteri, by 
frequent movements, first irritates and erodes the vaginal 
mucous membrane and then the cancer cells become 
implanted on the wound surface. 



EXTENSION BY CONTACT OR IMPLANTATION SI 

Against such a method of- implantation of cancer, it 
is urged that a carcinoma of the cervix uteri is always 
infected and that the implantation of cancer cells in the 
presence of infection is not possible. There can be no 
doubt that the presence of this infection is unfavorable 
to the formation of a contact growth. If it is remembered 
that the primary growth is constantly in contact with the 
erosion in the vaginal mucous membrane, it must be 
accepted that the probabilities are in favor of cancer 
cells being so implanted in some cases that they will 
continue to grow. 

A further argument against these secondary growths 
in the vagina being true contact cancers is that they 
can be explained in another way, which to some observers 
seems more rational. These observers claim that these 
growths are retrograde metastases; that is, that they are 
metastases formed by cancer cells being carried in lym- 
phatic vessels or veins in which the direction of the flow 
lias been reversed. In support of this view are mentioned 
those cases in which there are beneath the vaginal mucous 
membrane malignant growths secondary to a carcinoma 
of the cervix. This is frequently seen in cases of chorio- 
epithelioma of the uterus. These cases of submucous 
growths cannot, on account of their locations, be contact 
growths, but if they were not seen until a later stage when 
they had ulcerated, they would have all the appearance 
of such growths and might erroneously be so considered. 

It is probable that some of the cases of secondary 
growths in the vagina are due to retrograde metastases 
and that sonic are due to contact implantation. 

There is another method of implantation on mucous 
membrane that is described, and about which there is 
much more doubt. There are cases reported in which 
it is supposed that a secondary cancer of the stomach 
is produced by swallowing pieces of cancer tissue or cancer 

cells from a cancer of the tongue or cheek. In the same 
way a secondary growth of the intestine is believed to 
result from a primary tumor higher in the gastrointestinal 
(i 



82 CONTAGIOUSNESS OF CANCER 

tract. Cases are reported of carcinomata of the lungs 
resulting from the implantation of cancer cells or tissue 
from a similar growth in the larynx or trachea. 

It is exceedingly doubtful whether cases of this kind 
ever occur. In the gastro-intestinal tract, it is doubtful 
if minute pieces of cancerous tissue could withstand 
the action of the digestive juices. Differing from the 
cases of contact cancer of the vagina, in these cases the 
cancer is not in continuous contact with the eroded or 
diseased mucous membrane. It would be much more 
rational to explain these cases as multiple primary tumors. 
Carcinoma of the tongue and of the stomach are frequent 
diseases, and chance would bring them together in the 
same individual as frequently as implantation tumors of 
this kind are supposed to exist. 

It is difficult to believe that cancer cells from a growth 
in the larynx could obtain lodgment and grow in the 
mucous membrane of the smaller bronchi. It is more 
probable that any piece of tissue would be treated as a 
foreign body and be expelled or encysted. 

Cases of contact cancer are also reported between the 
upper and lower lips, between the tongue and cheek, and 
between the two sides of the vulva. In each of these 
instances, the primary cancer is in constant contact with 
the opposite tissue, and it is probable that true contact 
cancers are seen in these places. 

Implantation on the Skin. — It must not be supposed that 
a cancer can be engrafted on the normal skin. As with 
the mucous membrane, the skin must be eroded and 
ulcerated before the cancer cells can be implanted. The 
most frequent cases of this kind are seen about the breast. 
Either in a heavy pendulous breast, the ulcerated car- 
cinoma is in contact with the skin of the chest wall, or 
the location of the growth brings it in contact with the 
upper arm. First, a simple ulceration is formed and on 
this the cancer cells become implanted. 

Fate of Cancer Cells Entering the Circulation. — As has 
been described, cancer cells become separated from the 



EXTENSION BY CONTACT OR IMPLANTATION 83 

primary tumor, enter the lymphatic, venous and arterial 
systems and are carried to various parts of the body, 
forming the secondary growths or metastases. It is not 
believed that all the cancer cells that leave the primary 
tumor in this way ultimately form the metastases, but 
that many of them are destroyed. 

In the lymphatic glands, beyond doubt many cancer 
cells are destroyed. It is probable that a growth while 
still small and in an early stage may give off cells and 
that these are destroyed in the lymphatic glands. These 
glands probably act toward cancer cells as they do toward 
other detached body cells. It is only after the lymphatic 
glands have been overwhelmed, after they have been given 
more work than they can accomplish, that the cancer cells 
obtain a lodgment and form a metastasis. Even then 
the action of the lymphatic glands in destroying cancer 
cells goes on, as is shown by the spontaneous cure of 
metastases in such glands. 

In the veins and arteries, cancer cells are carried to the 
various parts of the body. In the arterial system the 
blood is carried to the minute capillaries into which the 
arteries divide. Any foreign bodies in the arterial system 
are ordinarily lodged evenly in the capillaries throughout 
the body, that is, the muscles, bones, viscera, etc., all 
have deposited in them approximately the same amount 
of the foreign substances. This is not the rule in regard 
to the formation of metastases in malignant diseases. 
Certain organs, such as the liver and lungs frequently 
show metastatic deposits; other structures, such as the 
muscles, rarely show these secondary growths. It is 
assumed, therefore, that at some point the cancer cells 
that are carried to the muscles are destroyed to a 
greater extent than those that are carried to the liver 
and lungs. 

There is no way to know how many cancer cells enter 
the blood from the primary and numerous secondary 
growths. It is not conceivable that the number is as 
small as the number of metastases that are found in 



84 CONTAGIOUSNESS OF CANCER 

malignant conditions. It is probable, judging by the 
knowledge of other conditions, that the entrance of cancer 
cells into the circulation is a frequent and not an unusual 
occurrence. If each cancer cell that entered the blood 
found ultimate lodgment and became a metastatic growth, 
the number of such growths would probably soon become 
very large, much larger than are usually found. 

It is not possible to tell exactly where the cancer cells 
that enter the blood and fail to produce a metastatic 
growth are destroyed. It may be in the blood; it may 
be in the tissues after the cells have become lodged. 
It is most probable that it is in the tissues, and not in the 
circulating blood. 

CACHEXIA. 

Cachexia is the late constitutional manifestations of the 
malignant process. The general clinical picture is quite 
characteristic of cancer, and the term cachexia is generally 
applied to the condition that results from the cancerous 
growth; there is, however, nothing that is really distinctive 
about cancerous cachexia. Any of the known changes and 
a similar picture may be produced by other diseases and 
the term cachexia might be, and in fact is, sometimes 
applied to the general condition seen in the terminal 
stage of various chronic exhausting diseases. The term 
is, however, more frequently applied to constitutional 
conditions of a patient in the late stage of a malignant 
growth. 

The time at which cachexia appears varies in different 
cases, and depends both on the type of the growth and 
the organ in which it is situated. In general, there is less 
cachexia in sarcomata than in carcinomata, though there 
are marked exceptions. The cachexia in the mildly 
malignant epithelioma of the face comes much later and 
is less marked than in the rapidly growing carcinoma of the 
breast. The cachexia of a carcinoma of the cervix uteri 
which sloughs early and may be the source of a secondary 
infection, appears earlier and is more marked than in a 



CACHEXIA 85 

growth that does not ulcerate until later, if at all. A 
carcinoma of an organ necessary for nutrition and life, 
such as the stomach, liver, etc., causes cachexia earlier 
than a similar growth in a less important organ, such 
as the uterus or breast. 

Cause. — The cause of the cachexia cannot be assigned 
to a single influence. By the ancient writers the cachexia 
of a malignant growth was looked upon as a separate 
disease and not as a result of the cancer. Later, when 
"cancer juice" was looked upon as the active agent of 
cancer and as the cause of all local and general mani- 
festations of the malignant process, its absorption in the 
blood and general system was considered the cause of 
the cachexia. Still later this idea of the absorption of the 
"cancer juice" was modified, and the breaking down 
and absorption of the cancerous tissue of the growth 
itself was believed to produce the cachexia. At present 
many writers believe the absorption of the products 
of the cancer cells that have entered the blood as such 
is the principal cause of the cachexia. 

In general, all of these different theories agreed that the 
cause of the cachexia is the absorption of products of one 
kind or another from the growth which were injurious 
to the various body functions. 

With our present beliefs, part of which are based 
on theoretical knowledge and part on clinical experience, 
the causes of the cachexia can practically be arranged 
under two headings: (1) Absorption of decomposition 
products, toxines, etc., from the primary tumor and its 
metastases, and (2) interference with the functions of 
the various organs. 

Probably the most important absorption products 
are from the destruction of cancer cells after they have 
entered the blood or lymphatic vessels. It is probable that 
the absorption of the products resulting from the destruc- 
tion of cancer cells begins early. It has been repeatedly 
demonstrated that the lymphatic glands near a malignant 
tumor show early signs of special activity even when 



86 CONTAGIOUSNESS OF CANCER 

there is no metastatic growth in them. This would indicate 
that cancer cells or other tumor products enter the lym- 
phatic glands even at this early stage. A careful examina- 
tion will detect the results of this absorption before general 
cachexia has developed. For instance, there may be 
changes in the blood or an irregular fever. 

A second form of absorption from a malignant tumor 
occurs when it breaks down and becomes secondarily 
infected. The absorption of these septic products has 
the same effect as a similar process would under other 
conditions. 

It is quite possible that there are also other absorption 
processes going on from the malignant growth of which 
nothing is now known and which are etiological factors 
in cachexia. 

Interference with the functions of organs may be 
caused in two ways: There may be first, the mechanical 
interference due to the presence of the malignant growth. 
A cancer of the esophagus, stomach, or intestine may 
mechanically interfere with the function of one of these 
organs, which would interfere with the nutrition of the 
patient and in this indirect manner add to the rapidity 
and extent of the cachexia. Other cancers will add 
mechanically to the cachexia, depending on the organ 
in which they are situated. 

The second way in which the functions of organs are 
interfered with by a malignant growth, is through the 
absorption of toxic products. That is, the absorption of 
toxins may interfere with the function of such organs as 
the stomach, liver, etc., and in this indirect manner may 
increase the cachexia. 

The blood changes in malignant tumors is, according to 
Naegeli, due to four causes: 

1. The action of the toxins on the blood-forming organs. 

2. Secondary infections. 

3. Destruction of blood-forming organs by the primary 
growth or its metastases. 

The extent of the changes in the different elements 



CACHEXIA 87 

of the blood depends on the type, stage, location, and 
extent of the growth. 

The red blood cells are usually reduced in number if 
the case is at all advanced. In most cases the reduction 
in the number of red blood cells will be present before 
other symptoms of cachexia will appear. The lowest 
count in Cabot's series of cases was 1,457,000; other 
observers report numerous cases below 1,000,000. 

In some cases there may be no diminution in the red 
blood cell count, even though the case is well advanced, 
and in still other cases the red cell count may be actually 
considerably increased. These conditions are due to a 
concentration of the blood and not due to an increase in 
the actual number of red blood cells. The concentration 
of the blood and increase in the red blood cell count is 
seen in malignant tumors that interfere with taking and 
absorbing fluids, such, for example, as carcinoma of the 
esophagus or stomach. In Cabot's series of 129 cases of 
gastric cancer, there were over 6,000,000 red cells in 4 
cases and between 5,000,000 and 6,000,000 in 23 cases. 

As a rule, the hemoglobin percentage is low. In 87 
cases of malignant tumors in the series of Cabot, the 
hemoglobin ranged from 20 to 100 per cent., with an 
average of 58 per cent. The percentage of hemoglobin 
may be low even with a normal red blood count. 

Morphologically there are marked changes in the red 
blood cells. Their size may be decreased. In advanced 
cases, and in some early cases, nucleated red blood 
cells are usually found. Usually the nucleated red blood 
cells are of normal size but they may be increased. The 
shape of the red blood cells may also be changed. 

The white blood cell count is usually moderately 
increased. In 91 cases of malignant disease Cunlifi'e 
found an average total white count of 14,864. The highest 
average white counts found by Cunlifi'e were in the 
cancers of the cervix uteri (22,800) and of the stomach 
(17,280). The high count in these cases illustrates the 
influence of bleeding and infection in causing a leuko- 



88 CONTAGIOUSNESS OF CANCER 

cytosis in carcinomata. The nature of these eases is such 
that both bleeding and infection were present. In one 
case, reported by Cunlift'e, of a carcinoma of the cervix 
uteri with repeated hemorrhages and ulcerations into the 
bladder and rectum the total count was 69,200. Such 
a high count is, of course, very exceptional. In a few 
cases the white blood count is decreased. Cabot speaks 
of the decrease in some cases of carcinoma of the esophagus 
due to starvation. Cunliffe found a count of only 32,000 
white cells (the smallest number in his series) in a case 
with mildly malignant growths of the peritoneum. 

The causes of leukocytosis in malignant tumors are 
found in the complications rather than in the growth 
itself. These complications are hemorrhage, ulceration 
and infection, metastases, and rapid growth. The leuko- 
cytosis may disappear with the removal of the growth 
by operation and return if there is a recurrence. Some 
observers believe that an increasing leukocyte count 
indicates a return of the disease. A recurrence large 
enough to cause a leukocytosis could probably be recog- 
nized in most situations by other means, and the diagnostic 
help of such an examination would not be great. 

Symptoms. — The symptoms of the cachexia are gradual 
but progressive. The rapidity with which they develop 
is subject to wide variations. The color of the patient is 
described as a straw pallor, and is not unlike that of 
secondary anemia. The change in color is due mostly to 
the diminution of the hemoglobin in the red blood cells. 

The emaciation is a late symptom, but is usually present 
before the termination of the disease. There are, however, 
exceptions to this rule. The emaciation is due to dis- 
turbances of the gastro-intestinal tract, with the resulting 
loss of appetite, nausea, vomiting, etc. 

Pain may be local in the primary growth or in the 
metastases or reflected from them. There also may be 
pains suggesting rheumatism in different parts of the 
body from the absorption of toxic substances. There 
are also exceptions in regard to the presence of pain. 



CACHEXIA 89 

Occasionally a patient with a cancer ma}' have neither 
local nor general pain during any part of its course. 
Frequently the secondary infection of the ulcerated growth 
is the cause of the greatest amount of pain. Much can 
be done for the relief of pain in such a case by keeping the 
wound clean. 

Fever is usually considered to be absent in cases of cancer 
if there is no ulceration or secondary infection. If there 
is an increase in the temperature and ulceration and 
infection of the growth are present they are sufficient to 
explain it, and are probably the real cause. 

In the absence of ulceration and infection it is more 
difficult to explain the slight increase in the temperature 
that is present in some cancer cases. The most probable 
explanation is the absorption of decomposition products 
or toxins from the tumor or its metastases. It is believed 
by some observers that a temperature is more often 
present and more marked if the primary growth or its 
metastases are in the parotid gland, the liver or the 
blood-forming organs, also if the cancer is of the acute, 
rapidly growing type, such, for example, as is sometimes 
seen in the breast during pregnancy. 

A different type of fever is seen in some cases, especially 
in those cases which are greatly emaciated and have 
been largely without food for some days, shortly before 
the final termination of the case. 

Coma is the terminal condition in occasional cases. 
This was first specially described by Jaksch. 

LITERATURE. 

f'unlifiV. Medical Chronicle, September, 1903. 

Jaksch. Wien. klin. Woch., 1883, Band xxxiii, S. 473 and 521. 

Wolff. Die Lehrc von der Krchs Krankheit. 



CHAPTER IV. 
SPONTANEOUS CURE OF CANCER. 

Formerly it was believed that a cancer was never 
spontaneously cured. This belief applied equally to the 
primary growth and also to the metastases. It was 
generally accepted, if even the smallest portion of the can- 
cerous growth remained in the tissues, that it was sure 
to continue to grow and to form a recurrence. In a case 
which was believed to be cancer, either the primary 
tumor, or a portion of it which was known not to have 
been removed at an operation, disappeared, its disappear- 
ance was considered sufficient proof that the original 
growth was not a cancer. In fact, the definition ordinarily 
given of a cancer included a statement that it showed no 
tendency to spontaneous healing. It is now generally 
accepted that spontaneous healing of a primary malignant 
tumor does occur, though these cases are certainly rare. 

There are several factors that are known to influence 
the spontaneous cure of cancer. The degree of malignancy 
of the growth is an important factor. For example, 
more cases of spontaneous cure of the mildly malignant 
epithelioma of the face seem to occur than of the more 
malignant cancers, such as occur in the breast. In general, 
the smaller the amount of tumor tissue left the greater is 
the chance of spontaneous healing. This is seen especially 
in incomplete operations. The smaller the amount of 
malignant tissue that remains after an operation the more 
likely is a spontaneous cure of this tissue to take place. 

The type of tumor has also an important bearing on the 
subject of spontaneous cure of malignant growths. It is 
undoubted that more cases of sarcoma than carcinoma 



METASTASES 91 

undergo spontaneous cure. Sarcoma is a tumor that is 
sometimes not easily diagnosed even by a microscopic 
examination. The histological structure of it closely 
resembles that of other lesions, and an error in diagnosis 
is not infrequent. In different laboratories the same 
specimen is diagnosed differently. This is well illustrated 
in the different percentages of sarcomatous degeneration 
of fibromata of the uterus that are reported by different 
observers, even though sufficiently large series of cases 
are considered to minimize the element of chance. Some 
observers find only 1 or 2 per cent, of such cases and others 
report 8 or 10 per cent. Sarcomata vary even more than 
carcinomata in the degree of malignancy. Some cases, 
though undoubtedly sarcomata, are of slight degree of 
malignancy. All of these factors have an influence in the 
greater frequency of spontaneous healing of sarcomata 
than of carcinomata. 

The spontaneous cure of cancer is best considered 
separately for the three conditions: (1) metastases; 
(2) incomplete operations; (3) primary tumors. 

Metastases. — The spontaneous cure of metastases is 
probably most positively demonstrated in cases of malig- 
nant papillomata of the ovaries. In the early stages of this 
disease there is a cyst wall with papillomatous outshoots in 
the interior. Later either by spontaneous rupture or by 
penetration of the cyst wall there is a tumor covered on 
its external surface by the papillomatous growths. Still 
later there is an accumulation of fluid in the peritoneal 
cavity, and the peritoneum is covered seemingly every- 
where by innumerable papillomatous metastases. In 
many of these cases the removal of the primary tumors 
is followed by the disappearance of the papillomatous 
iik tastases on the peritoneum. This is proved not only 
by the disappearance of the ascites previously present 
and the subsequent health of the patient, but also in 
numerous cases by direct inspection of the peritoneal 
cavity at a second operation performed for hernia or some 
entirely new lesion in the abdomen. 



92 SPONTANEOUS CURE OF CANCER 

The cases of this type are so frequent that they have 
been seen by most abdominal surgeons, and demonstrate 
conclusively for malignant papilloma of the ovary, 
which is a malignant growth, though its malignancy is 
distinctly different than that of other forms of cancer, 
that its metastases may undergo spontaneous cure. 

The cases of malignant papillomata of the ovary in 
which spontaneous cure of peritoneal metastases most 
frequently occurs are those in which the peritoneum is 
covered by a large number of minute metastases and in 
which there are no large metastatic growths. It is possible 
that these cases of peritoneal metastases illustrate a 
similar, though more minute, condition that exists in all 
malignant growths. It is probable, from all malignant 
growths that have attained definite size, that cancer 
cells are given off and are lodged in the neighboring 
vessels or tissues where they may become engrafted or 
maintain an independent existence. These minute 
aggregations of cancer cells undoubtedly in many cases 
are destroyed, as has been seen in cases of peritoneal 
metastases in malignant papillomata of the ovaries. 

The way in which these small metastases are cured 
can be discussed only theoretically. It is known that the 
cancer cell is relatively a weak cell. It is destroyed by 
substances that will not interfere with normal tissue 
cells. It is probable that there exists in the body, possibly 
developed by the cancer itself, a substance which is 
antagonistic to the cancer cell, and that this substance is 
present in sufficient quantity to overwhelm single or small 
groups of cells, but insufficient to destroy large masses. 
Such an explanation, however, is entirely theoretical and 
does not give any real insight into the manner by which 
the cells are destroyed. 

The spontaneous cure of malignant metastases in the 
lymphatic glands has various clinical proofs. The micro- 
scopic proof is more positive, but more difficult to obtain. 

In the early stage of a malignant growth, as has already 
been stated, it is probable that many cancer cells are given 



METASTASES 93 

off which may become lodged in the tissues or which may 
be carried to the neighboring lymphatic glands. It is 
possible in the early stages that many such cells are 
destroyed in the glands in the same way that other foreign 
elements are destroyed. If the axillary glands, in cases 
of carcinoma of the breast, or the iliac glands, in cases of 
carcinoma of the cervix uteri, are examined, they are 
often found enlarged and hyperemic, though no malignant 
growth is present in them. This condition is sometimes 
looked upon as an inflammatory enlargement. It is 
probable, however, that the hypertrophy, in part at least, 
is due to the reaction resulting from toxins or cells carried 
to the lymphatic glands from the primary growth. The 
hypertrophy of the lymph nodes in the vicinity of a 
malignant growth may be considered as practical proof 
or as an intimation of the destruction of cancer cells 
in the glands. 

If a gland is removed and found on examination to 
contain a malignant growth it is probable that other 
enlarged glands in the immediate vicinity are involved 
in the same manner. The only positive proof, however, 
is the microscopic examination, and this is possible only 
by removal of the gland. There is little doubt, however, 
if enlarged glands that are removed are found to be 
malignant, that similar glands that are not removed, 
particularly if hard and indurated, are similarly involved. 

There are numerous cases reported in the literature, 
in which glands of this kind were left at the time of the 
removal of the primary malignant growth, and which 
disappeared, as shown by the subsequent course of the 
disease. For example, Peterson quotes a case of Beck's, 
of resection of the pylorus of the stomach for carcinoma, 
leaving carcinomatous glands in the vicinity. Three 
years later, at autopsy, these glands were found to be 
free of malignant growth, though there was a carcinoma of 
the sigmoid flexure. Such a case as this demonstrates the 
spontaneous cure of malignant metastases in lymphatic 
glands. Similar cases arc sufficiently frequent in the 



94 SPONTANEOUS CURE OF CANCER 

literature to furnish definite clinical evidence that such 
cures are probably of frequent occurrence. 

Only a theoretical explanation of the spontaneous cure 
of these metastases can be given. The removal of the 
primary growth removed the source from which there 
was probably a constant flow of toxins and cancer cells 
in sufficient quantity to overtax the power of resistance 
of whatsoever nature it may be that existed in the lymph 
nodes. After the removal of this excess tax on the lymph 
nodes they are able to destroy the cancer cells that had 
already started to grow in the gland. Of the real nature 
of these toxins, as well as of the resisting power of the 
lymphatic glands, we have as little knowledge as we have 
of other phenomena of cancer growth. 

There are other clinical observations which are ad- 
vanced as evidence of the spontaneous cure of malignant 
metastases in lymphatic glands. The radical vaginal 
operation for carcinoma of the cervix uteri, as performed 
in the Schauta Clinic, does not include the removal of 
the iliac glands, as is done in the radical abdominal 
operation for the same condition as performed in the 
Wertheim Clinic, yet the number of recurrences following 
the vaginal operation is practically no greater than fol- 
lowing the abdominal operation. It is claimed by some 
observers that this indicates that, following the vaginal 
operation, the diseased iliac glands frequently undergo 
spontaneous healing. This, however, is weak and un- 
certain evidence of the spontaneous cure of the cancerous 
metastases. The lymphatic glands in cases of carcinoma 
of the cervix uteri that are suitable for the radical vaginal 
operation are frequently not involved by the malignant 
disease. Furthermore, there may be certain technical 
advantages in the radical vaginal operation that offset 
the advantage in the radical abdominal operation of 
removing the iliac glands. 

Examples of the spontaneous cure of malignant metas- 
tases in internal organs occur in the literature. Schmidt 
reported a metastasis in the lung from a gastric carcinoma, 



INCOMPLETE OPERATIONS 95 

in which a definite retrograde process was seen. The 
spontaneous cure of metastases in internal organs and 
in the bones is less frequent than in the lymphatic glands. 
The amount of malignant tissue in metastases in lymphatic 
glands is smaller than in most organs, and doubtless the 
smaller the amount of malignant tissue the greater is 
the chance of spontaneous healing. The function of the 
lymphatic glands seems to be to fight and destroy any 
foreign elements that reach them and to act as barriers 
for the protection of the system as a whole, and it is 
probable that their power of resisting and destroying 
cancer cells is greater than that of other organs. 

Incomplete Operations. — Positive cases of the spon- 
taneous cure of cancers are seen following incomplete 
operations for malignant growths. Usually following an 
incomplete operation, the cancerous growth increases 
with greater rapidity, due probably in part to exposing 
the fresh wound surface on which cancer cells become 
implanted and in part to forcing cancer cells mechanically 
into the tissues by the manipulation of the growth during 
the operation. That these are the causes of the increased 
rapidity of growth', usually seen after an incomplete 
operation, is confirmed by the absence of such increased 
rapidity of growth, if the malignant tumor is incom- 
pletely removed or destroyed by the cautery. In destroy- 
ing a growth with a cautery, fresh wound surfaces on 
which cancer cells might become implanted are not made, 
iii id there is also less manipulation of the growth. 

As an incomplete operation usually increases the 
rapidity of the growth, and a spontaneous cure of the 
malignant tissue not removed is a rare occurrence, partial 
operations should be avoided. When necessary to remove 
a part of the inoperable growth to relieve symptoms, 
if possible, the cautery should be used. 

As examples of the spontaneous cure of cancerous tissue 
following the partial removal of the primary growth, 
Czerny reported two cases of incomplete operations for 
carcinoma of the large intestines, which were well at the 



90 SPONTANEOUS CURE OF CANCER 

end of four and five years. Theilhaber reports a case of 
Rotter, of a young woman with a malignant adenoma of 
the rectum which returned after operation. The recur- 
rence subsequently disappeared spontaneously and was 
not found at autopsy three years later. 

The cases of disappearance of a malignant growth, 
following the use of the cautery or caustics by which 
malignant tissue was not completely removed, should 
not be considered cases of spontaneous cures. The work 
of Byrne, twenty years ago, and the more recent work of 
Percey have shown that the effect of cauterizing extends 
deeply into tissues and destroys cancer cells. The same 
is true of caustics even though they have of late properly 
fallen into disrepute. 

Primary Tumor. — The spontaneous cure of the primary 
tumor is of less frequent occurrence than that of metastases 
or of portions of the growth which are left after partial 
removal of the primary growth. Though exceedingly 
rare, there are well-authenticated cases in which it has 
occurred. 

The most frequent way in which spontaneous cure 
occurs in the primary malignant growth is by sloughing. 
Not infrequently polypi of the cervix uteri or of the 
intestine are found to be malignant without involvement 
of the organ to which it is attached. If such a polyp 
were to slough away, as any polyp is liable to do, it' is 
easy to understand that the malignant growth is spon- 
taneously cured. 

Another example of the cure of a malignant growth 
by sloughing is that of cancer of the face that disappeared 
and did not return after an attack of smallpox. 

The cases that are cured in this way by sloughing 
or by necrosis are examples of spontaneous cures in 
the sense that they occur without outside interference. 
They result, however, from the accidental destruction of 
the growth and the process is in no way different than 
the destruction of the growth by any other means, and 
it is not to be compared with the spontaneous healing 



PRIMARY TUMOR 97 

of malignant metastases or cancerous tissue that is left 
at an incomplete operation that has been described. 

Similar cases of the spontaneous cure of primary 
malignant tumors do occur. For example, Czerny 
reported a case of inoperable carcinoma of the cervix 
uteri which became infected with erysipelas and was 
cured. The patient was well and free of recurrence at the 
end of five years. Czerny also has reported the disappear- 
ance of a recurrence of a carcinoma of the breast after an 
attack of erysipelas. The reason for the disappearance 
of the malignant growth following an attack of an infec- 
tious disease is not known. It has been suggested that 
the high temperature kills the weak cells of the growth. 
Under certain conditions the toxins of the infectious 
disease seems to exert a destructive influence on the cancer 
cells. This has given the hope that a serum containing 
these toxins may be made that will have a curative action 
in cases of carcinoma. Sera made according to different 
formulae have been extensively used, and definite claims 
have been made of successful results. The results gener- 
ally obtained by the use of these sera, however, have not 
been sufficiently successful to have them universally 
used. It is possible that the future will produce a serum 
that will have a result in cancerous conditions that is 
comparable to that obtained by salvarsan in syphilitic 
diseases. 

A change in the local conditions without any attempt 
at removal has been followed by a spontaneous cure 
of the primary cancerous growth in a number of cases. 
This is most frequently seen in the gastro-intestinal 
tract, and a number of cases of the disappearance of 
the primary tumors following palliative operations are 
reported. For example, Czerny reports cases of carcinoma 
of the stomach which were treated by gastroenterostomy 
and in which the primary tumor disappeared. There is 
in these cases a doubt regarding the diagnosis. 

There is still another class of cases of spontaneous 
oiirc of primary malignant growths which appears in the 
7 



98 SPONTANEOUS CURE OF CANCER 

literature. This class includes cases that have all the 
clinical appearance of malignant tumors, and are diagnosed 
as such by thoroughly competent observers, but which, 
after reaching a certain stage of growth, cease growing, 
decrease in size, and ultimately disappear. These cases are 
so extremely rare that their occurrence at all is doubted 
by some observers, and an error in diagnosis is urged 
to explain their disappearance. 

There seems to be no doubt that cancer cells may 
remain quiescent in the tissues for years, as is seen in 
cases of late recurrences. There is also no doubt, as has 
already been described, that cancerous tissue following 
incomplete operations, and malignant metastases, may 
be spontaneously cured. Cancer on the face has been 
observed to partly heal. Such observations as these, 
that is, the inactivity of cancer cells for a period of years, 
the spontaneous cure or partial healing of a malignant 
process, demonstrate conclusively that there exists in 
the system a definite resistance and destructive action 
to the growth of the cancer cells. By analogy to 
other diseases, it is probable that some individuals 
possess this power to a greater extent than others. It 
is fair to assume theoretically with all conditions favor- 
able, that is, with an individual with special resistance 
to the growth of cancer cells, with a primary growth of a 
small degree of malignancy, with other conditions of 
which at present we have no knowledge, that a primary 
malignant growth may undergo spontaneous cure. Some 
of trje cases that are reported in the literature were seen 
by careful observers, the diagnosis was made by a micro- 
scopic examination and the completeness of the cure was 
confirmed by autopsy after death from other causes. 
More positive and convincing clinical histories are rarely 
obtained. It must therefore be accepted that the spon- 
taneous cure of primary malignant tumors do occur even 
though they are extremely rare. No case should be con- 
sidered as such a cure unless the diagnosis was made by 
a microscopic examination by a competent pathologist, 



MULTIPLE PRIMARY CANCERS 99 

and the cure demonstrated by an autopsy or the lapse 
of a long period of years. 

Spontaneous cure of primary sarcomata undoubtedly 
occurs more frequently than of carcinomata. 



MULTIPLE PRIMARY CANCERS. 

There is nothing in a malignant tumor, either a sarcoma 
or a carcinoma, so far as is known, that protects the 
individual from another cancer. As a matter of chance, 
therefore, multiple primary malignant growths should be 
expected. Just as it is possible to have existing in the same 
person two benign tumors which have no relationship 
to each other, such as a lipoma of the back and a fibro- 
myoma of the uterus, so also a combination of a benign 
and a malignant or two or even more malignant growths 
may be present at the same time in the same individual. 
There may be a sarcoma and a carcinoma or two sarcomata 
or two carcinomata in the same patient or even in the 
same organ. This is all a matter of chance. Multiple 
benign tumors of the same or different types are more 
commonly seen than multiple primary malignant tumors, 
because benign tumors are more common than malignant 
tumors, there are many more varieties and their duration 
is longer. The duration of a malignant tumor is relatively 
short. 

Care must be taken to distinguish between multiple 
primary malignant growths and metastases. If the 
malignant tumors are of different histological structure, 
for example, if one is a sarcoma and the other a carcinoma, 
or it' one carcinoma is composed of squamous and the other 
of cylindrical cells, there is no question that they are 
independent primary malignant growths. 

If two malignant growths have the same histological 
structure each may be a metastasis from another tumor, 
which is giving no symptoms and cannot be diagnosed. 
In fact, the primary lesion may be so overshadowed by 



100 SPONTANEOUS CURE OF CANCER 

the symptoms and courses of the secondary growths that 
it may never even be suspected. 

There are reported in the literature numerous authentic 
cases of multiple tumors of the same histological structure 
which were undoubtedly both primary growths. It is 
probable that these cases are more frequent than is 
generally suspected, and as the reported cases would 
indicate. 

Some cases of multiple primary malignant growths 
are the result of the same etiological cause. Excellent 
examples of such growths have been seen, and micro- 
scopically demonstrated, in the cutaneous cancer of 
workers in tar, paraffin, soot, etc. In these cases the 
same irritation, under the same conditions, natural re- 
produces the same result— epithelioma. Williams reports 
such a case in a worker in asphalt who developed three 
independent malignant growths on the face, two of which 
were epitheliomata and the third a cylindrical-celled 
carcinoma from a sweat gland. Similar multiple primary 
malignant growths of the skin are reported which result 
from multiple lesions of the skin. Steinhauser reports 
such cases. Hutchinson reports cases of multiple rodent 
ulcers. 

Cases of primary sarcomata of the skin, which, so far 
as is known, are primary growths, are described in books 
on dermatology as idiopathic multiple pigmented sar- 
comata. These cases may be multiple metastases from 
a single primary growth. 

In the uterus, multiple tumors of the same histological 
structure cannot positively be demonstrated as primary 
growths, though it is possible that they may be. If, for 
example, there is a columnar-celled carcinoma of the 
cervix and also one of the fundus, one is probably second- 
ary to the other. Cases are reported of carcinomata of 
different varieties occurring in the cervix and fundus 
uteri. Gellhorn describes such a case. Young and others 
report cases of carcinoma of the uterus and breast. 
Schminche reported a case of carcinoma of the gall- 



MULTIPLE PRIMARY CANCERS 101 

bladder and sarcoma of the uterus. Emanuel reported 
a case of carcinoma and sarcoma in the same uterus. 

In the breasts, as in the uterus, if the growths are of the 
same histological structure the chances are that one is 
secondary to the other. Carcinoma of both breasts 
occur in 1 or 2 per cent, of the cases, but one is prob- 
ably secondary to the other. Williams reports a case of 
bilateral cancer and refers to others. 

In the g astro-intestinal tract, multiple primary malignant 
tumors, according to Williams, are more frequent than in 
any other part of the body excepting the skin. Different 
parts of the gastro-intestinal tract have the same chronic 
irritation and possibly also the same polypi, and the 
multiple primary malignant growths are the natural 
results. Even though the histological structure of these 
tumors is the same, if the case is seen at an early stage, 
and before there is a general carcinosis, they can properly 
be considered multiple primary growths. Metastases 
from a malignant growth in the intestinal tract do not 
usually occur in other parts of the mucous membrane 
of the intestine in the early stage. In addition to these 
multiple tumors of the same histological structure, there 
are various different varieties reported. For example, 
Frangenheim reported a case of sarcoma and carcinoma 
of the esophagus. Bushnell and Hinds reported cases of 
carcinoma of the stomach and sarcoma of the ovary. 

Malignant and Benign Tumors. — These occur frequently 
together, and the association is usually of little practical 
importance. If a malignant growth exists in an organ, 
and there is also a benign tumor in another part of the 
body, they are not considered to be related in any way, 
and one is not influenced by the other. This association 
of benign and malignant growths in different organs is 
so common in the experience of all surgeons, that no 
cases will be quoted from the literature. 

If the benign and malignant tumor are both in the 
same organ, then the association is of more interest, 
because it raises the possibility that in some cases the 



102 SPONTANEOUS CURE OF CANCER 

malignant growth is the result of the benign tumor. 
For example, the benign polyp of the rectum is frequently 
in some cases the antecedent of the malignant growth. 
The relationship of benign to malignant tumors has, 
however, been considered elsewhere. 

REFERENCES. 

Brans' Beitrage, 1894, Bd. xii, S. 501. 

Bushnell and Hinds. Zeit. f. Kreb., i, 3, S. 184. 

Emanuel. Zeit. f. Geb. u. Gyn., Bd. 34, S. 1. 

Frangenheim. Arch. f. Path. Anat., Bd. 184. 

Gellhorn. Zeitsch. f. Geb. u. Gyn., 1897, Bd. 36, S. 430. 

Hutchinson. Archives of Surgery, 1891, iii, 318, 335. 

Mandry. Beitrag. z. klin. Chir., 1892, Bd. viii, S. 589. 

Petersen, Beitr. z. klin. Chir., 1902, Bd. 32. 

Richter. Wien. klin. Woch., 1905, S. 865. 

Schminche. Arch. f. Path. Anat., 1906, Bd. clxxxiii, S. 160. 

Trans. Path. Soc, London, 1905. 

Williams. Diseases of the Breast, 1904, p. 302, etc. 

Williams. Twentieth Century Practice of Medicine, xvii, 228. 

Young. Archives of Middlesex Hospital, 1904, iii, 165. 






CHAPTER V. 
CARCINOMA AND SARCOMA OF THE BREAST. 

CARCINOMA OF THE BREAST. 

Frequency. — In the United States registration area in 
1912, which included approximately 63 per cent, of the 
entire population, there were 4431 deaths recorded from 
malignant tumors of the breast. For the entire United 
States in the same proportion there would have been 
slightly over 7000 deaths from cancer of the breast, or 
about 10 per cent, of all cancer deaths. Of the females 
who died of cancer, the breast was involved in 15.1 per 
cent, of the cases. 

Williams, in the study of the mortality returns for 
England and Wales, found 15.8 per cent, of the cancer 
deaths of females due to cancer of the breast. 

In the Middlesex Hospital, as reported by Campiche 
and Lazarus-Barlow, cancer of the female breast con- 
stituted 21.78 per cent, and of the male breast 0.29 per 
cent, of malignant disease of all organs. Of cancer in 
females alone, the breast was the organ involved in 35.29 
per cent. 

The difference in the percentage of deaths in mortality 
records, approximately 15 per cent, of females, and that 
for hospital cases, approximately 35 per cent, of females, 
is explained by the location and relative ease with which 
carcinoma of the breast is recognized. Cancer of more 
obscure origin is recognized later and those affected apply 
less frequently for hospital treatment, but ultimately are 
recorded in mortality statistics. 



104 CARCINOMA AND SARCOMA OF BREAST 

Age. — The following' table gives the percentages by age 
groups of the cases that died of cancer of the breast as 
reported in the United States registration area for 1912: 

20 to 29 years 0.9 per cent. 

30 to 39 " 8.0 " 

40 to 49 " 20.0 

50 to 59 " 27.0 

60 to 69 " 20.0 

70 to 79 " 15.0 

80 to 89 " 6.0 



The following table, adapted from Judd and Sistrunk, 
gives the ages by decades of 651 cases at the Mayo Clinic: 

20 ta 30 years 2.0 per cent. 

30 to 40 " 22.0 

40 to 50 " 35.0 

50 to 60 " 22.0 

60 to 70 " 14.0 

Over 70 " 4.0 

99.0 



These tables confirm the usual observations that cancer 
of the breast is rare under thirty years and most frequent 
at about fifty years of age. It will be noticed that one 
table is of mortality records and the other from hospital 
records. There are a few cases reported in the literature 
under the age of twenty-five years. Handley states that 
it is unknown before puberty. 

Sex. — About 1 per cent., or slightly less of the cases of 
carcinoma of the breast, occur in males. 

Civil State. — As recorded in the Middlesex Hospital 
Reports, of 1000 female patients with cancer of the breast, 
77.2 per cent, were married and 22.8 per cent, were 
unmarried. It was estimated that this ratio was ap- 
proximately the same as the proportion of married and 
unmarried females over twenty-five years of age in the 
general population during the same period. The ratio 
of married to unmarried women in cases of cancer of the 



CARCINOMA OF THE BREAST 105 

breast, as determined by other observers is somewhat 
higher than that in the Middlesex Hospital. Schwartz- 
kopf in 395 cases found 86.5 per cent, married, and quoted 
eighteen other observers with an average of 83 per cent, 
of cases in married women. 

If the percentage of married and unmarried women 
among the cases of cancer of the breast is the same as it is 
among women in the general population, as was reported 
in the Middlesex Hospital Reports, then married women 
are no more subject to cancer of the breast than single 
women. This would mean that acute and chronic 
mastitis, lactation, etc., which are present in married 
women, exert no influence in the development of cancer 
of the breast. It is generally accepted that various 
conditions in the breast, directly or indirectly the result 
of child-bearing, do favor the development of cancer, 
and that there is a larger percentage of married women 
among the cases of cancer of the breast than in the general 
population. 

Mastitis. — Schwartzkopf reported that 10.7 per cent, 
of all cases and 22 per cent, of those who had children, 
in his series gave a history of mastitis. These figures 
in themselves are not absolute proof of the influence of 
mastitis in the development of cancer, as the frequency 
of mastitis in non-cancerous cases is not known, but it 
undoubtedly is considerably less than the percentages 
given above. 

A further observation in Schwartzkopf's series, which 
is of greater significance in showing the undoubted influ- 
ence of the mastitis in the development of carcinoma of 
the breast is the frequency with which the carcinoma 
developed in the same breast as the mastitis. If the 
mastitis did not influence the development of the carci- 
noma, the two lesions would not so frequently have 
involved the same breast. 

In Schwartzkopf's series the average period between 
the mastitis and the carcinoma was 12.8 years; the 
extremes were four months and thirty-eight years. The 



106 CARCINOMA AND SARCOMA OF BREAST 

long period between the mastitis and the development of 
the carcinoma would indicate that the scar from the 
mastitis was the causative factor. 

Errors of Lactation. — Leaf , in an analysis of 73 cases of 
carcinoma of the breast who had borne children found 
that 2 cases had nursed normally, 10 cases had not nursed 
at all, 1 case had deficient milk supply, in 21 cases there 
was overlactation on one or more occasions, in 8 cases 
there was underlactation on one or more occasions, and 
in 30 cases there was both overlactation and underlactation 
in different pregnancies. 

It is not easy to determine always what constitutes 
an error in lactation. It would seem, however, as Leaf 
maintained, that the number of cases in his series in which 
lactation had been abnormal was higher than would be 
expected in general. 

Leaf believed that overlactation would so damage 
the secretory cells that there would be an increased 
disposition to the development of cancer. Also, that 
by underlactation, the retention of the milk in the breast, 
would act as an irritant to the secretory cells and favor 
the development of a malignant growth. This, however, 
is largely theoretical, and further observations must be 
made before the real influence of errors in lactation can 
be determined. 

Chronic Cystic Mastitis. — This disease of the breast is 
most frequent between the ages of forty and fifty years, 
and is common between the ages of thirty and sixty years; 
that is, the ages during which it is most frequently found 
corresponds to the ages of greatest frequency of cancer of 
the breast. The disease has been described by various 
writers, and a large number of different names have been 
applied to it. By some it is believed that the formation of 
cysts is the result of a chronic inflammation. It may occur 
in only one or in both breasts, it is probably more frequent 
in married than in single women, and, as has been stated, it 
is most frequent at the menopause. As causes of chronic 
cystic mastitis, are given various influences which interfere 



CARCINOMA OF THE BREAST 107 

with the normal functions of the breast, such as acute 
mastitis, abnormal lactation, menstruation, etc. 

Etiology. — Many of the etiological factors of chronic 
cystic mastitis are the same as those of carcinoma of the 
breast, and there is a close relationship between the two 
diseases. The tendency of chronic cystic mastitis is to 
advance and to involve more and more of the breast. 
With the formation of more cysts there is also a tendency 
to proliferation of cells. This is sometimes so to such an 
extent that some writers have considered it a true neo- 
plasm, and have assigned to the lesion the name of a 
neoplasm. 

In this connection, as elsewhere, it is not possible to 
state absolutely that the carcinoma is the direct result 
of the chronic cystic mastitis, and would riot have 
developed if the chronic cystic mastitis had not previously 
existed. The relationship between the two diseases, 
however, is such that there is greater evidence that chronic 
cystic mastitis does influence the development of a cancer 
of the breast than there is of many of the etiological 
factors given for carcinoma in this and other organs. 

The frequency with which carcinoma ultimately 
develops on chronic cystic mastitis cannot be determined 
definitely. Warren found carcinoma associated with the 
chronic cystic mastitis in 13 per cent, of his series. This, 
however, gives the frequency with which carcinoma was 
associated with the chronic cystic mastitis at the time 
the removed tissue was examined. It does not indicate 
the additional cases that would have developed if the 
chronic cystic mastitis had not been removed. Judd 
states "that many of the best authorities believe the 
condition occurring in women of the cancer age will 
become malignant in more than half of the cases." 

This evidence should indicate two things in the treat- 
ment of chronic cystic mastitis. In a woman of the 
cancer age, chronic cystic mastitis should be removed as 
a precancerous lesion, and should always be examined at 
once, to discover if there is any malignant tissue associated 



10S CARCINOMA AND SARCOMA OF BREAST 

with it, so that a radical operation can be done if it is 
found necessary. 

Diagnosis. — The diagnosis of chronic cystic mastitis 
is not difficult, but it is impossible to positively exclude 
a malignant change in it, excepting by a microscopic 
examination after it has been removed. The examination 
should be thorough, and include all parts of the tissue 
removed. 

Trauma. — The breast is an organ so placed that it is 
exposed frequently to injury, and it is not strange, there- 
fore, that a history of definite traumatism is frequently 
obtained in cases of carcinoma of the breast. This 
traumatism may be a single one, or may be repeated 
slight injuries, as from poorly fitting corsets or carrying 
weights against the chest. 

At the Middlesex Hospital there was a history of injury 
to the breast in 18.7 per cent, of all cases of mammary 
carcinoma. Leaf reported history of injury to the affected 
side in 32 per cent, of the cases. In the series of Schwartz- 
kopf there were 34 cases, or 8.8 per cent., with a history 
of injury. The varieties of injuries which he recorded 
include blows, sting of wasp, prick of needle, etc. The 
average percentage of cases that gave history of trauma 
of twenty-one authors reported by Schwartzkopf was 9.2 
per cent. 

The interval of time between the injury and the first 
symptoms of the cancer of the breast varied from two 
months to twenty years. In 13 of the 34 cases the 
interval was less than two years. 

Trauma is proportionately more frequently an etiological 
factor in carcinoma of the male than of the female breast. 

Pathology. — The scirrlms carcinoma is made up largely 
of fibrous tissue, with scattered areas of cancer cells. 
The growth is hard and nodular, and early becomes 
adherent to the skin or to the pectoral fascia. The scirrhus 
carcinoma of the breast does not ulcerate at all or only 
late in the disease. The contraction of the fibrous bands 
produces the puckering of the skin and the retraction 



CARCINOMA OF THE BREAST 109 

of the nipple. On section the growth is sufficiently 
hard to offer considerable resistance to the knife. 

The medullary carcinoma of the breast grows more 
rapidly than the scirrhus, forms a larger tumor, and 
frequently ulcerates, forming a fungus growth. The 
growth is made up more largely of cellular elements 
than the scirrhus variety. On section, the growth is 
soft and may offer little resistance to the knife. Though 
the growth is not encapsulated, there is a distinct outline 
between it and the normal breast tissue. 

Between the medullary and the scirrhus types there are 
all variations; even in different parts of the same tumor 
different varieties may be found. 

Location. — The location of the primary growth in 1010 
cases of carcinoma of the breast as reported in the archives 
of the Middlesex Hospital and of 177 cases reported by 
Schwartzkopf is given in the following table : 





Middlesex hospital. 


Schwartzkopf. 


Beneath the nipple .... 


12.2 per cent. 




In the nipple ' 


7.6 




Superior and outer quadrant . 


44.9 


46 . 89 per cent. 


Superior and inner quadrant . 


16.7 


15.82 


Inferior and outer quadrant 


12.4 


27.12 


Inferior and inner quadrant . 


6.2 


9.6 



100.0 



It will be noticed that about one-half of all the cases 
began in the upper and outer quadrant. 

Side Affected. — It is probable that carcinoma of the 
breast involves the right and left breast with about equal 
frequency. In the Middlesex Hospital in 1512 cases the 
left breast was involved in 777 cases, and the right in 735 
cases. In Schwartzkopf's series of 395 cases the left 
breast was involved in 197 cases and the right in 198 
cases. The difference in each of these series is too small 
1<> consider that carcinoma occurs more frequently in one 
breast than in the other. Other observers have found a 
slight difference in favor of the right breast. Observers 



110 CARCINOMA AND SARCOMA OF BREAST 

who have believed that the right breast is involved more 
frequently have explained it by the greater use of the right 
arm. Those who believe in the greater frequency of 
involvement of the left breast explain it by carrying the 
child more frequently on the left arm. The influence of 
these etiological factors cannot be great and their difference 
even less. The statement that has been made that one 
breast is involved with approximately the same frequency 
as the other is the best decision that can be made from 
our present evidence. 

Both Breasts.— Both breasts are found involved by 
carcinoma in a few cases; for example, in Schwartzkopfs 
series both breasts were involved in 4 cases in a total 
of 395 cases. There are two ways by which the occurrence 
of carcinoma in the two breasts can be explained. One 
explanation is that a carcinoma develops in each breast 
at practically the same time, each growth entirely inde- 
pendent of the other. The other explanation is that one 
growth is a metastasis from the other. This is probably 
the correct explanation of most cases. Theoretically there 
is no reason to deny the possibility of a carcinoma starting 
simultaneously in each breast, and when the frequency 
of carcinoma of the breast is considered the chances are 
in favor of such an occurrence. Campiche and Lazarus- 
Barlow state, "Not a single indubitable instance of primary 
cancerous growth originating separately in both breasts 
is recorded at the Middlesex Hospital/' Rodman is of 
the opinion that one breast is always affected before the 
other, and that the second breast is involved by metastasis 
from the first. 

It is well at this point to consider the frequency with 
which the second breast is involved by a metastatic 
growth, either late in the course of the disease in inoperable 
cases or in cases following operation. At the Middlesex 
Hospital in 1512 cases there was a secondary involvement 
of the other breast in 137 cases, or in 9 per cent. In 35 of 
these cases, in which the point was recorded, the interval 
between the beginning of the primary growth and the 



CARCINOMA OF THE BREAST 111 

involvement of the second breast was, on the average, 
three years. Rodman quotes Rotter, that in 35 recurrences 
6 were in the opposite breast. 

The usual explanation of the involvement of the second 
breast is that it takes place through the lymphatics beneath 
the skin or by the anastomosis of the lymphatics of the 
two sides in the anterior mediastinum. Handley believes 
that the involvement of the second breast is by the 
permeation of the malignant growth along the lymphatic 
vessels across the middle line. 

Extension of Carcinoma of the Breast. — As with carcinoma 
in other parts of the body, that of the breast extends 
largely through the lymphatic vessels, and involves the 
lymph nodes, organs, bones, etc., in remote parts of the 
body. It also spreads by direct extension, and through 
the bloodvessels. The permeation theory advanced by 
Handley is described later. A better understanding of 
the ways by which carcinoma of the breast spreads has 
greatly improved the operative results of the disease. 

Lymphatic Glands. — The lymphatic vessels of the breast 
run in four directions, and extension of carcinoma takes 
place in each one of them. The largest number extend to 
the axillary glands. This is true of the superficial and 
also of the deep lymphatics, and of the inner as well as the 
outer part of the breasts. From the axillary glands the 
supraclavicular and cervical glands may be involved. 
A second set of lymphatic vessels, probably only super- 
ficial ones, pass upward over the clavicle and involve 
the supraclavicular glands directly without first passing 
through the axillary glands. There are only a few of 
these lymphatic vessels, and the supraclavicular glands 
are not frequently involved in the carcinoma of the 
breast, excepting at the late stage of the disease, and when 
they are diseased it is usually indirectly through the 
axillary glands. A third set of lymphatic vessels pass to 
the lymphatic glands in the anterior mediastinum. It is 
probable thai they intercommunicate with the opposite 
side, and that it is through these channels thai the second 



112 CARCINOMA AND SARCOMA OF BREAST 

breast is sometimes involved. This is on the theory that 
when there is a carcinoma in each breast, one is primary 
and the other secondary, and not that both are primary 
growths. Fortunately, there are not many of these 
vessels, and early involvement of the mediastinal lymph 
nodes is rare, as these glands are beyond the reach of 
our present diagnostic and operative technique. At the 
Middlesex Hospital the bronchial and mediastinal glands 
were found at autopsy to be involved in 17 per cent, of 
470 cases. The fourth set of lymphatic vessels are those 
that pass directly across from one breast to the other. 
These lymphatic vessels are also few in number, but may 
be the channel through which the other breast is second- 
arily involved. 

Of these four sets of lymphatic vessels the one that leads 
to the axillary glands is the largest, and drains all parts of 
the gland. The condition of the axillary glands is an 
important diagnostic help with tumors of the breast, and 
their routine removal is a part of the technique of all 
modern operations for carcinoma of the breast. Ulti- 
mately, if the course of the disease is not checked, they 
are involved in most cases. At the Middlesex Hospital 
in a series of 470 cases which came to autopsy, the axillary 
glands were found involved in 75 per cent, of the cases. In 
9 per cent, the axillary glands of both sides were involved. 

It would be of distinct value if the period of the disease 
at which the axillary glands are generally first involved 
could be determined. It would, of course, not be the 
same in all cases. In an analysis of 500 cases at the 
Middlesex Hospital "a lump" in the axilla was the first 
symptom of carcinoma of the breast that was noticed in 
2 per cent, of the cases. 

Schwartzkopf found in 12 cases, in which the history 
seemed sufficiently reliable to be of value, that the average 
interval between the first sign of a tumor in the breast 
and an enlargement of the axillary glands was 7.46 months. 
The number of cases in this series is small and, as Schwartz- 
kopf himself points out, the source of the information 



CARCINOMA OF THE BREAST 113 

must necessarily be of a nature that its accuracy is 
uncertain. 

Viscera. — The following table gives the frequency with 
which metastases were found in different organs in 470 
cases of carcinoma of the breast which came to autopsy 
at the Middlesex Hospital: 

Liver . . 45 . per cent. 

Lungs 35.0 " 

Parietal pleura 35 . " 

Kidneys 9.0 

Adrenals 7.0 " 

Ovary 5.0 " 

Brain 5.0 

Stomach and intestines 3.0 " 

Pancreas 3.0 " 

Spleen 2.5 

The liver is the organ most frequently involved by the 
metastatic growth in carcinoma of the breast. This 
occurs probably in most cases through the general lym- 
phatic and blood circulation. In part also through 
lymphatic vessels that accompany the vessels of the 
rectus muscles and enter the liver through the triangular 
ligament. 

The lungs and pleura are involved less frequently 
than the liver, though they are in close relationship 
to the breast. The lungs and pleura may be involved 
through the general lymphatic and blood circulation, or 
from the mediastinal, infraclavicular, or supraclavicular 
glands, that may have received the infection directly 
from the breast. In other cases there may have been a 
direct extension of the growth in the breast through the 
thoracic wall to the pleura and lungs. In some cases the 
extension is from the lungs to the pleura. 

Bones. — The osseous system seems to be more frequently 
involved in the secondary growths in carcinoma of the 
breasl than in carcinoma of other organs. The following 
table gives the Dumber of times various bones were found 
in 170 eases of autopsy for eareinoma of the breast at the 
Middlesex Hospital: 
8 



m CARCINOMA AND SARCOMA OF BREAST 

Ribs 41 cases. 

Vertebral column • . 32 " 

Femur ". 28 " 

Skull 16 " 

Humerus 15 " 

Clavicle 9 " . 

Leg 2 " 

Forearm 1 " 

The ribs, sternum, and clavicle may be involved by 
direct extension from the primary growth in the breast. 
The humerus may be involved from the axillary glands. 
The involvement of the bones, excepting in cases where 
they are involved by direct extension, is probably through 
the blood system. It will be noticed by the table that 
the humerus and femur are involved more frequently 
than the bones of the forearm or of the leg, and most 
statistics agree with this observation. Rodman, however, 
does not accept this, and believes that the findings are 
due partly to incomplete autopsies and partly to the 
more frequent occurrence of spontaneous fractures of 
the femur and humerus than of the bones of the leg and 
forearm. 

Permeation of Cancer. — It is universally accepted that 
carcinoma cells spread through the lymphatic vessels 
to the lymph nodes. The nodes may for a time filter out 
the cancer cells, but ultimately they pass the glands and 
reach the general blood system. There is no question that 
the carcinoma may grow directly into the lumen of a 
bloodvessel and that cancer cells may be washed off into 
the general circulation. This embolic method is the 
process that is generally accepted to explain metastatic 
growths in organs remote from the primary carcinoma. 
There are, however, certain recognized facts that are 
not satisfactorily explained by this theory. Handley has 
made an extensive study of the dissemination of cancer 
of the breast, and has explained it in part by what he 
has termed the permeation process. Handley, against an 
embolic process as an explanation of dissemination of 
cancer of the breast, raises the point that various organs 



CARCINOMA OF THE BREAST 115 

on the average should be attacked with the same relative 
degree of frequency if this was the result of an embolic 
process. The spread of cancer cells by an embolic process 
should affect various organs with the same relative fre- 
quency as those organs are affected in pyemia, which is 
also spread by an embolic process. Such, however, is not 
the case. For example, in pyemia the liver and the 
spleen are involved in the ratio of 3 to 2; in carcinoma of 
the breast the ratio is approximately 14 to 1. He also 
urges against the embolic theory that the same viscus is 
involved by a secondary growth with different degrees of 
frequency by carcinomata of different organs. That is, 
the liver is involved secondarily more frequently when 
the primary growth is in the breast than when it is in the 
uterus. Handley accepts the embolic process as one 
method by which cancer is spread, but believes the per- 
meation process is of equal or greater importance, and 
must be accepted in order to explain certain faults in the 
embolic theory. 

According to the permeation theory the cancer cells 
grow along the lymphatic vessels centrifugally from the 
primary growth. Handley describes this by the following 
illustration: Certain bacteria cannot be forced through 
a porcelain filter, but if they remain in it for a time 
they grow through its pores and can be detected on its 
outside. In the same way the cancer cells grow in the 
lymphatic vessels against the current of lymph. When 
the pressure of the growth is sufficient to overcome the 
wall of the lymphatic vessel it breaks through and sets 
ii]) around it an inflammatory reaction. The result of 
this inflammatory reaction may be the destruction of the 
cancer cells and the lymphatic vessel is replaced by a 
fibrous band. Handley calls this the perilymphatic fibrosis. 
Instead of the cancer cells being completely destroyed, 
some may escape and form isolated carcinomatous nodules. 
The perilymphatic fibrosis never quite overtakes the 
permeation, so the disease continues to spread at the outer 

edge. There are, in this way, formed about the primary 



116 CARCINOMA AND SARCOMA OF BREAST 

growth, as a centre, three zones. In the outer zone the 
process of dissemination is extending centrifugally in a 
constantly enlarging circle. In the inner zone the process 
has been largely checked by the cancer cells being killed 
and the lymphatic vessels being replaced by fibrous bands 
by the perilymphatic fibrosis. In places in this inner 
zone there may be isolated carcinomatous nodules made 
up of cancer cells that have escaped destruction. In 
the middle zone, which is relatively narrow, the perilym- 
phatic fibrosis is actually changing the outer active zone 
of permeation into the inner zone of secondary nodules 
and destroyed lymphatics. This is an interesting example 
of the local cure of a cancerous process. 

In the early stage of the disease the outer edge of the 
zone of permeation is not far from the primary growth. 
As the disease progresses this zone of permeation increases 
in circumference and the edge may be, according to 
Handley, two feet from the primary growth, reaching to 
the scalp, the back, to the groins, and to the thighs. This 
growing edge can by proper examination be detected 
microscopically, but of course cannot be detected by 
other means. 

By the permeation theory of the dissemination of 
cancer of the breast, Handley explains certain features 
that do not correspond to an embolic process. This is 
particularly true of subcutaneous nodules which occur in 
certain cases. Not infrequently the primary tumor in 
the breast is surrounded by a complete circle of sub- 
cutaneous nodules. In some cases, similar subcutaneous 
nodules are found in more distant parts of the body, 
though the thoracic or abdominal viscera are not involved. 
Such conditions are well explained by the permeation 
theory, and it is probable that these lesions are formed in 
the general way described by Handley. 

The dissemination to the abdominal organs is also 
explained by Handley by the permeation theory. The 
lower and inner margin of the breast is close to the epigas- 
tric angle, and at this point the deep fascia in which the 



CARCINOMA OF THE BREAST 117 

carcinomatous permeation is progressing is close to the 
peritoneum. After the peritoneum, the upper surface 
of the liver through its serous coat is first involved, and 
later by gravitation the organs lower in the abdomen. 
This will explain the greater frequency with which the 
liver is secondarily involved in cases of carcinoma of the 
breast, and also the cases in which a number of the abdomi- 
nal viscera are involved, but all the thoracic viscera have 
escaped. The permeation theory is not as generally 
accepted to explain visceral dissemination as it is to 
explain the subcutaneous nodules. 

Handley also applies the permeation theory to the 
involvement of the osseous system. He believes that 
the bones are involved by secondary growths in about 
the order previously given from the Middlesex Hospital 
records. That is, that the bones nearer to the breast, 
the ribs, sternum, clavicle, vertebra, cranium, humerus, 
and femur are involved more frequently than the bones, 
such as the radius, ulna, tibia, fibula, and bones of the 
hands and feet, which are farther away, because they are 
reached sooner by the process of permeation. 

Symptoms. — First Signs. — The following table gives 
the five most frequent first signs in an analysis of 500 
cases at the Middlesex Hospital : 

Growth in breast . . . 315 cases or 63.0 per cent. 

Growth and pain ... 57 " 11.4 " 

Pain alone 72 " 14.4 

Retraction of nipple ... 19 " 3.8 " 

Growth in axilla .... 10 " 2.0 

One or another of these five symptoms is the first sign 
of a carcinoma of the breast in 95 per cent, of the cases. 

Growth in the Breast. — This is the first symptom in 
three-quarters of the cases of carcinoma of the breast. 
Some writers state that it is the first symptom in a larger 
percentage of the cases. The growth in the early stage 
can be best felt with the palm of the hand, and it is in 
practically all cases single and it is movable. The hard- 



118 CARCINOMA AND SARCOMA OF BREAST 

ness which is characteristic of a carcinoma may be difficult 
to detect in the early stage when the growth is still small. 
Practically, in the early stage when the growth is still 
small, there is no way, other than by its removal and a 
microscopic examination, to determine whether a tumor 
of the breast is benign or malignant. The indication, 
therefore, is to remove every tumor of the breast in order 
to exclude the possibility of overlooking a malignant 
growth. The only exception to this rule is a tumor that 
is known to have existed for a long period and has shown 
no recent signs of activity, and tumors in women under the 
age that carcinoma is likely to occur. The duration of 
its existence may be sufficient to exclude its malignancy, 
but even if the growth is benign, its removal is probably 
the best treatment, as a malignant change may occur in 
the benign tumor. At the Middlesex Hospital between 
1900 and 1904, of all tumors of the breast 89 per cent, were 
shown to be malignant. The part of the breast in which 
the growth occurs has already been given. 

Pain. — Pain either alone or associated with a growth 
was the first symptom in 25 per cent, of the quoted cases 
at the Middlesex Hospital. This percentage is probably 
higher than that usually given. As a rule, pain is not 
an early symptom of carcinoma of the breast, and when 
present it is of a mild type. In the advanced stage of the 
disease the pain may be severe, and may be due to pressure 
on the brachial plexus or other nerves, to edema of the 
arm, or to secondary deposits in the bones or internal 
organs. Usually the presence of real pain indicates that 
the growth has passed the operable stage. 

Retraction of Nipple. — This was the first symptom 
noticed in 3.8 per cent, of the 500 studied cases at the 
Middlesex Hospital. It was recorded as a symptom in 
26 per cent, of all cases at that hospital. It is more 
frequently a symptom of carcinoma of the breast when 
the growth is situated near the nipple. It is usually 
not an early symptom when the growth is distant from 
the nipple. It may be present in other conditions than 



CARCINOMA OF THE BREAST 119 

carcinoma, and may be absent in carcinoma. The retrac- 
tion of the nipple does not mean that the case is inoperable. 

Probably most cases, in which retraction of the nipple 
is recorded as the first symptom, were patients who gave 
little attention to local conditions or whose breasts were 
so large that the growth could not easily be detected. 

Axillary Glands. — The enlargement of the axillary 
glands is an important, though not usually an early 
symptom, of carcinoma of the breast. Schwartzkopf 
estimates that the interval between the first symptoms 
of the disease and the enlargement of the axillary glands 
averaged about six months. Enlargement of the glands 
in the axilla may be due to other causes than the growth 
in the breast. The enlargement of the axillary glands 
does not indicate that the growth has reached an advanced 
stage, nor that it is inoperable, though the prognosis is 
less favorable. 

Discharge from the Nipple. — This may be brown, or 
bloody, or it may be cream color. A discharge from the 
nipple was the first symptom in l.G per cent, of the cases 
in the Middlesex Hospital series. 

Dimpling of the Skin. — As the growth approaches the 
surface there is a change in the skin. In the early stage 
this change may be a dimpling or retraction of the skin, 
which is apparent to the eye, or can be demonstrated by 
manipulation. The dimpling of the skin is due to con- 
traction or the formation of fibrous bands. At a late 
stage the skin becomes adherent to the growth, or the 
"pig-skin" appearance is seen. The sebaceous glands 
appear larger and may be especially marked by the 
accumulation of foreign matter in their orifices. The 
skin is thick and leathery, at first over the growth and 
later over most of the breast. This condition is most 
frequent in carcinoma, but may also be seen in other 
conditions, such as chronic mastitis, tuberculosis, and 
syphilis. 

Edema of the Arm.- This is a late and an infrequent 
symptom of carcinoma of the breast, and is due to inter- 



120 CARCINOMA AND SARCOMA OF BREAST 

ference with the lymphatic vessels. This interference 
may be with the large lymphatic channels by the growth, 
or the destruction of a large number of the smaller vessels 
by the permeation process, as is described by Handley. 
At first the arm shows the usual signs of edema. The 
skin pits on pressure, the arm increases in size, and there 
is limitation of its motion. Later, there is further increase 
in the size of the arm, the skin is hard and brawny, and 
there is a constant severe pain. 

Ulceration of the Breast. — This is a late symptom of 
the disease, and is becoming less frequent as patients 
seek relief earlier. At the Middlesex Hospital between 
1897 and 1903, 22 per cent, of the cases were ulcerated 
at the time of admission. At that hospital it was found, 
on the average, that the disease had existed about two and 
a half years before the ulceration began. 

Immobility of the Growth. — In the early stage, a car- 
cinoma of the breast is freely movable. Immobility 
indicates that it has become adherent to the pectoral 
fascia. This occurs earlier in the deep-seated cancer 
than in the more superficially located growths. If the 
growth has become adherent to the pectoral fascia and is 
fixed, while it may not be absolutely inoperable, it has 
reached a stage when the chance of a permanent cure is 
relatively small. 

Size of the Breast. — The size of the breast may be 
decreased by the contraction due to the growth even 
before there has been any ulceration. The size may also 
be decreased by the destruction of tissue due to the ulcera- 
tion. In other cases, particularly in those of rapid growth, 
the breast may be considerably increased in size. 

Treatment. — This is divided into the treatment of the 
operable and the inoperable cases. A case would be 
considered inoperable (1) if the growth is fixed to the 
chest wall, (2) if the involved lymphatic glands either 
in the axilla or the neck are fixed to surrounding tissue, 
(3) if there are cutaneous, visceral, or bony metastases. 
A case would be classified and treated as inoperable, if 



CARCINOMA OF THE BREAST 121 

there were a general constitutional disease which would 
soon terminate the life of the patient or would make an 
operation overhazardous. 

Inoperable Cases. — The benefit of radium or ar-rays 
is uncertain, but the use of either is entirely justifiable 
in cases of inoperable carcinoma of the breast, and either 
for the primary or any secondary growth. The external 
location of the breast makes a growth in it more accessible 
to the action of the rays than a growth in an internal 
organ, and greater benefit should therefore be expected 
from their use. The benefit obtained is by limiting the 
rapidity of the growth and the relief of the pain. It is 
doubtful if a case is ever cured by this means. Neither 
radium nor arrays should be used on a case that is suitable 
for operation. The plan of first using radium or .r-rays 
on an operable case previous to the operation is a waste 
of valuable time and should not be done. The use of 
.T-rays after the operation with the object of destroying 
any cells that may have been left in the tissues has much 
more to recommend it, and is practised by some surgeons. 
The use of drugs for the relief of the pain of an inoperable 
carcinoma of the breast should be delayed as long as 
possible and the milder sedatives used first. It must be 
remembered that the duration of a case that is inoperable, 
or which has recurred, may be some months, or even 
years, and if the use of morphin is started too early the 
discomforts of a morphin habit will be added to that of 
the carcinoma. Toward the end of the disease there is no 
drug equal to morphin for the relief of the pain, and it 
should not be withheld from the patient. 

Kdema of the arm may be a troublesome symptom on 
account of pain and sometimes of paralysis of the arm. 
In the early stage of the disease, relief of the swelling 
and of the pain can be obtained by the position of the 
arm. The support of the arm in a sling may be of comfort 
to the patient. Later the pain may require the administra- 
tion of morphin. 

The treatment of the ulceration is largely that of clean- 



122 CARCINOMA AND SARCOMA OF BREAST 

liness. This may be accomplished by sterile water or by 
the use of antiseptics, such as peroxide of hydrogen. The 
object is partly to remove discharges which may be 
offensive to the patient and partly to avoid secondary 
infection, which would add to the general discomfort. 
In some cases, troublesome hemorrhages may result from 
the ulceration and require treatment. 

Operable Cases. — If the local conditions of the growth 
and the general health of the patient are such that a 
radical operation, that is, the removal of the breast, 
pectoral muscles and axillary contents, can probably 
be successfully done, no other treatment should be con- 
sidered, and the operation should be done with the least 
possible, delay. 

Skin Incision. — The area of skin removed must be 
liberal to avoid the skin metastases and local recurrences 
that are frequent. This is an important point in all 
operations for carcinoma of the breast. If the wound 
cannot be entirely covered by the skin at the end of the 
operation the remaining area can be skin-grafted. 

Rodman believes that the favorable results obtained 
by Gross and by Banks, each curing about 21 per cent, 
of his cases, was due to the free removal of the skin, as 
neither removed the pectoral muscles and neither probably 
made as thorough an axillary dissection as is done today. 

The subcutaneous or paramammary fat is removed 
from an area even larger than the skin. This is partly 
for technical reasons, the undermining of the skin allows 
it to come together more easily, and partly to remove the 
lymphatic vessels and glands from a larger area. 

Axillary Contents. — The removal of the axillary glands 
as a part of the operation for carcinoma of the breast 
has been done since about 1875. Previous to that date 
the removal of the breast alone was the more frequent 
operation. At present the removal of the axillary glands 
with the surrounding fat, and as far as possible in one 
mass with the breast, is a necessary part of every operation 
for mammary carcinoma. 



CARCINOMA OF THE BREAST 123 

Supraclavicular Glands. — If these glands are diseased 
they should be removed. Some surgeons advocate their 
removal in all cases, but this is not generally accepted. 
If the supraclavicular glands are palpable, Judd removes 
one for microscopic examination. He states that his 
experience is "if the supraclavicular glands prove to be 
involved, that the patient lives longer and more com- 
fortably if not operated upon." The middle ground, 
that is, to remove these glands if they are found to be 
diseased, is the more usual course followed. 

Removal of the Pectoral Muscles. — Rodman gives to 
Volkmann the credit of first removing the pectoral 
muscles in operations for carcinoma of the breast. He 
apparently removed them only in the more advanced 
cases, but his results in these advanced cases with the 
removal of the pectoral muscles were more favorable than 
those of the less-advanced cases if the pectoral muscles 
were not removed. 

Halsted was the first to advocate, as he did in 1894, 
the removal of the pectoral muscle in all cases, even if 
early ones. The removal of the pectoral muscles is a 
more extensive operation, allowing the removal of tissues 
which frequently contained diseased lymphatic vessel 
and glands. It also allows a more thorough dissection 
of the axillary contents and the removal of any diseased 
glands that may be in the space between the pectoral 
muscles posterior to the pectoralis major. 

End Results. — Mortality. — With the improvement of 
general surgical technique the mortality following opera- 
tion for carcinoma of the breast has steadily decreased. 
At present the operative mortality is probably about 1 
per cent. The deaths that do occur are usually the result 
of surgical accidents, such as embolism or pneumonia, 
and not directly from the operation itself. The causes of 
death of l"> cases ( 1.0 per cent.) in Schwartzkopf's series 
were pneumonia (7), erysipelas (2), embolsim (2), hemor- 
rhage ( 1 ), miscellaneous (2). 



124 CARCINOMA AND SARCOMA OF BREAST 

Permanent Cures. — At the Mayo Clinic, as reported 
by Judd, of 266 cases of carcinoma of the breast which 
could be traced, 39.8 per cent, were alive at the end of 
five years, though 6 cases had recurrences; 14 of the cases 
in the series had died of other diseases. 

Schwartzkopf analyzed the results in his series of cases 
in regard to the local conditions. His results are estimated 
for a three-year period as a permanent cure. Of the cases 
the size of which was less than that of an egg, 34.26 per 
cent., of the size of an apple, 12.1 per cent., and of the 
size of a child's head, 5 per cent., were cured. Of the cases 
that were adherent to the skin, 17.2 per cent, were cured. 
Of the cases that were adherent to deeper structures 
there were no cures. Of the cases which had ulcerated, 
20 per cent, were cured. 

Schwartkopf divided his cases into three classes: (1) 
cases in which there were no palpable axillary glands, of 
which 80 per cent, were alive at the end of three years; 

(2) cases of moderate extent, that is, with involvement 
of the axillary glands, of which 20 per cent, were cured; 

(3) the most extensive cases, only 5 per cent, were cured. 
Regarding the variety of the growth, Schwartzkopf 

found of the cases of carcinoma scirrhosa 44.7 per cent, 
and of carcinoma simplex 18.9 per cent, were living at the 
end of three years. Of 10 cases of carcinoma medullare 
none were cured. 

Recurrences. — In a series of 82 cases of recurrences 
after operation, Schwartzkopf found that about 80 per 
cent, occurred during the first year following the operation. 
A number of cases of late recurrences are reported in the 
literature. Schwartzkopf reports one case that occurred 
at the end of eight years. Judd reports recurrences 
after five, six, nine, and twelve years, and speaks also of 
one reported by Matas at the end of twenty-five years 
and another of Ransohoff at the end of twenty years. 
Rodman believes that nearly all cases that are reported 
as late recurrences are not recurrences, but subsequent 
primary growths in cases that have shown special sus- 



SARCOMA OF THE BREAST 125 

ceptibility to the disease. Carcinoma of the various 
internal organs is relatively frequent, and it is easier to 
believe that the carcinoma of the breast was permanently 
cured and that the internal organ was attacked by a 
primary growth, than to believe that cancer cells remained 
dormant for twenty years, and then commenced to grow. 
The same reasoning can be used for the cases of late 
recurrences in the scar. It may be a new primary growth 
and not a recurrence of the original growth. 



SARCOMA OF THE BREAST. 

Etiology. — Frequency. — Sarcoma of the breast is an 
infrequent growth. Rodman in a collection of 5000 
tumors of the breast from reliable sources found that only 
2.78 per cent, were sarcomata. In the Middlesex Hospital, 
as reported by Campechi and Lazarus-Barlow, up to 1905 
only 45 cases of sarcoma of the breast had been recorded. 
Of these 45 cases, 43 were primary and 2 secondary 
growths. 

Age. — Sarcoma of the breast may occur at any age, 
but is most frequent in middle life. Rodman in an analysis 
of 100 cases found that one-half occurred between the 
age of forty and fifty years. The youngest patient at the 
Middlesex Hospital was twenty-three years of age. 

Trauma. — It is recorded that injury is a more frequent 
etiological factor in sarcoma than in carcinoma of the 
breast. This opinion is probably based more on the 
usual rule that sarcoma more frequently than carcinoma 
results from injury, than on actual experience, as the 
number of cases of sarcoma of the breast in any series is 
too small to give many definite instances of sarcoma directly 
following an injury to the breast. The more nearly correct 
statement would be that a larger percentage of cases of 
sarcoma, but a larger absolute number of cases of car- 
cinoma of the breast, gave a history of injury which was 
probably the cause of the development of the growth. 



12G CARCINOMA AND SARCOMA OF BREAST 

Lowenstein, in a series of 9 cases, recorded 5 carcinomata 
and 4 sarcomata of the breast following injury. 

Sex. — Sarcoma of the breast is much more frequent 
in females than in males. Among the cases reported in 
the Middlesex Hospital there was only one male in a 
total of forty-three cases of primary sarcoma of the 
breast. 

Location. — The growth may appear in any part of the 
breast. In twenty-six cases in which the location of the 
disease was definitely stated, as reported by Campeche 
and Lazarus-Barlow, the disease was more frequent in 
the upper than the lower half of the breast. 

Pathology. — Hertzler states that all varieties of sarcoma 
have been found in the breast, but that the simple or 
mixed celled is the most common. Various secondary 
changes may occur in the growth. 

Symptoms. — Sarcoma of the breast is usually a rapidly 
growing tumor and reaches a large size. The tumor is 
usually softer than a carcinoma and does not show the 
same tendencies to contraction of the skin or retraction 
of the nipple. Ulceration of the growth is a less frequent 
occurrence than with carcinoma. Hemorrhage is a fre- 
quent complication of the ulceration. Pain is a late 
symptom. 

Prognosis. — The average duration of life after the 
beginning of a sarcoma is probably between two and three 
years. 

Treatment. — The treatment of a sarcoma of the breast 
is the same as for a carcinoma. If the case is operable 
the same radical operation, that is, the removal of the 
pectoral muscles and the axillary contents together with 
the breast, should be performed. 

For the inoperable case the indications are the same 
as for carcinoma. 

End Results. — It is not possible to give any reliable 
statements in regard to the percentage of permanent 
cures, as the number of recorded cases is limited. 



SARCOMA OF THE BREAST 127 



LITERATURE. 

Campeche and Lazarus-Barlow. Middlesex Hospital Reports. 

Judd. Collected Papers, Mayo Clinic, 1913. 

Judd and Sistrunk. Surgery, Gynecology, and Obstetrics, vol. xviii. 

Leaf. Cancer of the Breast. 

Lowenstein. Ueber Unfallen und Krebs Krankheit. 

Mandry. Beitr. z. klin. Chir., Bd. viii, S. 589. 

Rodman. Diseases of the Breast. 

Warren. Surgical Pathology. 

Williams. Diseases of the Breast. 

Williams. Natural History of Cancer. 



CHAPTER VI. 
CARCINOMA OF THE UTERUS. 

Etiology. — Incidence. — With the possible exception of 
the stomach, carcinoma occurs in women more frequently 
in the uterus than in any other organ. It is not possible 
to state how much greater this frequency is, because there 
is with carcinoma of the uterus a difference among hos- 
pital, autopsy, and mortality statistics. There is also 
a difference between statistics of the present time and those 
of a few years ago. The uterus is an accessible organ, 
and most cases of cancer originating in it are diagnosed 
clinically and are correctly recorded in hospital and 
mortality statistics. The stomach is an inaccessible 
organ, and many cases of gastric cancer are not diagnosed 
and are incorrectly recorded in statistics. The percentage 
of recorded deaths from gastric cancer is increasing and 
may equal that of carcinoma of the uterus. 

In a study by Williams of 15,264 deaths of females, 
from cancer, reported in the Sixty-first Annual Report 
of the Registrar-General of England and Wales, the 
largest number, 23.5 per cent., were carcinoma of the 
uterus. The second largest number, 15.8 per cent., 
were of cancer of the breast. Cancer of the stomach was 
in fourth place, with 13.2 per cent, of cases. 

In the United States registration area for 1912, con- 
stituting about 63 per cent, of the population, there 
were 7089 deaths from cancer of the "female generative 
organs." This group included cancer of the uterus and 
probably of the ovary, Fallopian tube, and the vagina. 
At the same rate there were in the United States about 
11,250 deaths from cancer of these organs during the 



ETIOLOGY 129 

year 1912. This was about 25 per cent, of the total 
female cancer deaths for the year. If malignant growths 
of the ovaries, Fallopian tubes, and vaginae, which are 
relatively infrequent, were excluded it is probable that 
the percentage would about equal Bashford's statistics. 
It is probable, therefore, that cancer of the uterus is the 
cause of about one-quarter of the cancer deaths of females. 
Age. — Carcinoma of the cervix uteri occurs at an 
earlier age than carcinoma of the fimdus uteri. Carcinoma 
of the cervix uteri occurs most frequently between the 
ages of forty-one and fifty years, of the fundus uteri 
between fifty-one and sixty years. This is illustrated 
from the following table adapted from Knack: 



Carcinoma of 


the cervix uteri. 


Fundus uteri. 


Years. 


Cases. Per cent. 


Cases. 


Per cent. 


26 to 30 . . . 


16 4.0 


1 


1.5 


31 to 40 . . . 


80 20.2 


1 


1.5 


41 to 50 . . . 


143 36.2 


19 


28.8 


51 to 60 . . . 


115 29.0 


33 


50.0 


61 to 70 . . . 


38 9.6 


10 


15.2 


71 to 74 . . . 


4 1.0 


2 


3.0 



396 100.0 66 100.0 

This table fairly represents the frequency of carcinoma 
of the cervix uteri and of the fimdus uteri. It does not, 
however, give the extremes. In the 396 cases of carcinoma 
of the cervix there was no case under twenty-six years 
of age. The disease does occur at an earlier age though 
only rarely. Cragin reported one case of carcinoma 
of the cervix uteri in a girl under twenty years of age, 
and there are other cases in the literature. The oldest 
patient in the series was seventy-four years, but carcinoma 
of the uterus occurs at later years. 

Pregnancy. — It is not easy to determine the influence 
of pregnancies as a predisposing or an exciting factor 
in the development of cancer of the uterus. It is not 
possible to know the number of illegitimate births there 
have been in any scries of cases of carcinoma of the 
uterus. Neither is it possible to know the number of 
9 



130 CARCINOMA OF THE UTERUS 

such births in general so that the average number of births 
can be determined for comparison. There are, however, 
certain facts which, though not absolutely proved, are 
probably correct. They are not the same for carcinoma 
of the cervix and of the fundus uteri. 

Virgins. — Carcinoma of the cervix uteri is exceedingly 
rare in virgins, though it does occur. In a series of cases 
of carcinoma of the cervix uteri reported by Knack, 
there was no such case, and many clinicians of wide 
experience have never seen one. Carcinoma of the fundus 
uteri is more common in virgins than carcinoma of the 
cervix uteri. 

Nullipara. — Carcinoma of the cervix uteri is more 
common in nulliparae than in virgins. The probable 
explanation is the greater frequency of inflammation of 
the cervical canal and erosions of the cervix among 
married women even though they have had no children. 
Of the married women in Knack's series of cervical car- 
cinoma, 5.9 per cent, had never been pregnant. In 
Germany, as reported by Knack, 11.2 per cent, of mar- 
riages are childless; that is, there is a smaller percentage 
of sterile women among the cancer cases than in the 
general population. There is a smaller percentage of 
cases of carcinoma of the cervix uteri among women 
who have never been pregnant than among all married 
women of the general population. The difference is not 
great and there are two factors which would partly explain 
it. The age of the cancer cases was probably greater than 
that of the general population. The histories of the 
cancer cases, especially in regard to early pregnancies, 
abortions, etc., were probably more accurate than such 
records in regard to the general population, and more 
women who were not nulliparae would be counted as such 
from the general population than among the cancer cases 
whose histories were taken by physicians in whom they 
had confidence. It is difficult to conceive of anything 
about cancer of the cervix or the possible influences 
that cause it that would increase the chance of pregnancy; 



ETIOLOGY 131 

that is, that would dimmish the number of nulliparae 
as the figures themselves would indicate. It must be 
accepted, therefore, that next to virgins, women who 
have never been pregnant are least likely to develop 
carcinoma of the cervix uteri. 

The number of nulliparae among the cases of carcinoma 
of the fundus uteri is in distinct contrast to the number 
among the cases of carcinoma of the cervix uteri. Instead 
of being less than normal, as in the case of the latter, 
there are more than the normal number of women who 
have had no children among the cases of carcinoma of 
the fundus uteri. Of Knack's series, 18.8 per cent, of all 
the cases and 13.3 per cent, of the married women were 
childless. The average percentages of 14 observers 
quoted by him was 25.6 per cent. Some of the per- 
centages quoted were based on a small number of cases 
and were therefore subject to wide varition. The smallest 
percentage was 3.3 per cent, and the highest 56.3 per cent. 
Of 19 cases reported by Cullen, 10 cases, or 52 per cent., 
had never been pregnant. 

It must not be interpreted from the figures given that 
the chances of a woman having a carcinoma of the fundus 
uteri are diminished if she bears children. The probable 
explanation is that the conditions (whatever they may be) 
that influence the production of a carcinoma of the fundus 
uteri are also influential in causing the sterility. 

UniparcB, Multipara. — Of 364 cases of carcinoma of 
the uterus (including both the cervix and the body of 
the uterus) in married women as reported by Knack, there 
were an average of 5.6 full-term births for each woman 
compared with 4.15 to 4.3 such births for the married 
women of Germany. 

Of the eases in Knack's series of carcinoma of the 
cervix uteri, 11.2 per cent, had only one child and 82.3 
per cent, more than one. Of the cases of carcinoma of the 
fundus uteri, 22.3 per cent. lia«l one child and 61.1 percent. 
more than one. The percentage of married women who 
have more than one child, according to figures quoted by 



132 CARCINOMA OF THE UTERUS 

Knack, is between that for carcinoma of the cervix uteri 
and that of carcinoma of the fundus uteri and is probably 
about 76 per cent. This would indicate that cases of 
carcinoma of the cervix uteri have a larger number of 
children; in other words, an increase in the number of 
children increases the cases of carcinoma of the cervix 
uteri. This is not shown for carcinoma of the fundus 
uteri. The percentage of cases of carcinoma of the 
fundus uteri that have more than one child is considerably 
less than normal. There is in this the suggestion that 
some influence, possibly the result of the one pregnancy, 
produces both the sterility and the malignant growth of 
the fundus uteri. 

The following table from Theilhaber shows plainly 
the relationship between the number of births and the 
frequency of carcinoma of the cervix and of the fundus 
uteri : 



Number 


Carcinoma 




Number 


Carcinoma 




of births. 


of cervix. 


Per cent. 


of births. 


of fundus. 


Per cent, 





9 


2.9 





11 


27.5 


1 


25 


8.1 


1 


4 


10.0 


2 


29 


9.4 


2 


9 


22.5 


3 


36 


11.7 


3 


5 


12.5 


4 


23 


7.4 


4 


2 


5.0 


5 


34 


11.0 


5 


2 


5.0 


6 


40 


13.0 


6 


3 


7.5 


7 


111 


36.1 


7 


4 


10.0 



307 99.6 40 100.0 

This table indicates that as the number of births 
increase, there is in general an increase in the percentage 
of occurrence of carcinoma of the cervix uteri, but that 
the reverse is true for carcinoma of the fundus uteri. 
The largest number of the cases (27.5 per cent.) of car- 
cinoma of the fundus uteri were nullipara 3 , and, in general, 
the percentage decreased as the number of births increased. 
The average number of children for each case of carcinoma 
of the cervix uteri was 4.8, and for each case of carcinoma 
of the fundus uteri 2.5. Theilhaber found that the average 
number of children for women not suffering from cancer, 



ETIOLOGY 133 

but who had passed the child-bearing age, was between 
three and four. The number of children in the cases of 
carcinoma of the cervix uteri was above the average, but 
in those of carcinoma of the fundus uteri below average. 
Theilhaber found among women over forty-five years of 
age not suffering from cancer, 19.8 per cent, of sterility; 
among the cases of carcinoma of the uterus of corre- 
sponding ages, scarcely 4 per cent, of sterility. He also 
reported an interesting observation in regard to the 
relation between the average age at which carcinoma 
of the cervix uteri occurred in relation to the number of 
births. The average age at which carcinoma of the 
cervix uteri occurred in sterile women was fifty-seven 
years, in women with one child, fifty-one years, and 
in women with six children forty years. 

Abortion and Miscarriages. — It is difficult to show 
by statistics the relationship between cancer of the 
uterus and abortions and miscarriages. Even in countries 
and cities in which they must be legally registered the 
reports are, for obvious reasons, far from accurate. The 
most reliable statistics are from hospital records, as they 
are made by physicians in whom confidence is placed by 
the patient. These records are reasonably accurate for 
these cases, but they are records of patients, that is, of 
women who are ill and not of women in general. It is 
variously estimated that there is one abortion to every 
four to twenty full-term births. Knack, taking as an 
average for women in general one abortion in ten births, 
found abortions relatively more frequent than the average 
both for carcinoma of the cervix uteri and of the fundus 
uteri. His statistics show for carcinoma of the cervix 
uteri one abortion to every 8.5 births, which is slightly 
more frequent than the average, and for carcinoma of the 
fundus uteri, one to every 3.5 births. The greater relative 
frequency of abortions in cases of carcinoma of the 
fundus uteri is striking, and suggests that there may be 
in the uterus a condition that produces the abortion 
which may also be a factor in the development of the 



134 CARCINOMA OF THE UTERUS 

carcinoma. Theoretically, the action of abortions on the 
development of carcinoma of the uterus is probably 
the same as that of full-term pregnancies. With an 
abortion or miscarriage, the cervix may be injured even 
more than by a delivery at full term, when the cervix 
is more softened and dilates more readily. Naturally 
an injury or erosion which may be a factor in the develop- 
ment of a cancer would have the same influence whether 
the result of an abortion or a full-term delivery. 

Obstetric Operations. — There are no statistics available 
to prove the influence of the various obstetric operations, 
such as turning, the use of forceps, bags, cervical dilators, 
etc., on the production of uterine cancer, and it is hoped 
that in the future there will be more careful records of 
these procedures. 

Theoretically, as obstetric operations produce injuries 
and resulting inflammations, they may influence the 
development of uterine cancer. 

The influence of these agencies — pregnancies, abortions, 
and obstetric operations— is exerted by producing con- 
ditions which are the probable factors in the development 
of carcinoma of the cervix uteri. They are (1) lacera- 
tions, (2) erosions, and (3) cervical inflammation. These 
conditions cannot be separated; one is dependent upon 
the other; and it is not possible to state how or to what 
extent these conditions influence the development of a 
carcinoma of the cervix uteri. It is merely known, as 
has been shown, that carcinoma of the cervix is of more 
frequent occurrence the greater the number of pregnancies 
and that lacerations and erosions of the cervix uteri are 
the result of such pregnancies. It is also believed that 
injury, especially repeated injuries and chronic irritations, 
cause cancer, and therefore it is a fair assumption that the 
repeated pregnancies predispose to cancer of the cervix 
uteri by causing the lacerations, erosions, and cervical 
inflammations. 

Lacerations. — Lacerations of the cervix uteri are usually 
on one or both sides of the cervix. Carcinoma rarely 



ETIOLOGY 135 

begins on the side, but usually on the anterior or posterior 
lip. This is used as an argument against a laceration of 
the cervix uteri being a factor in the production of a 
carcinoma, and in reply it has been stated that in the 
anterior and posterior lips there are microscopic injuries, 
and in these microscopic injuries the cancer develops. 
This is probably not the way in which a laceration of the 
cervix uteri influences the development of a cancer. 

A cancer rarely develops in a healthy healed scar. 
Abdominal scars as the result of operations are numerous, 
but a cancer in such scars is practically unknown. At 
the orifice of the vagina from the rupture of the hymen 
and from injuries at confinements scars are very frequent, 
but carcinoma is equally rare. These injuries, however, 
are healed, and in such healed healthy scars carcinoma 
rarely occurs. Some lacerations of the cervix uteri 
which are produced at childbirth completely heal, though 
the evidence of the lesion is still present; that is, the 
laceration has been entirely covered over by the flat 
epithelium of the cervix. In such cases the external os 
is of normal size, there is no eversion of the cervical 
mucous membrane and no erosions. Such a case is 
probably little or no more likely to develop carcinoma of 
the cervix uteri than if no laceration had ever existed. 
In other cases the laceration divides the cervix into an 
anterior and a posterior lip, the cervical mucous membrane 
is everted, and erosions are formed. 

Lesions composed of the everted cervical mucous 
membrane, the so-called erosions, which heal slowly 
.nil I may exist for a long period of time, are formed in this 
way. It is in the long existing, unhealed lesion that car- 
cinoma is theoretically most likely to develop. These 
erosions, the result of a laceration, are mostly on the 
anterior and posterior lips. At the sides, at the angle of 
the laceration, where there is the greatest amount of scar 
tissue and where carcinoma is least likely to develop 
there are fewer or no erosions, and the flat epithelium 
of the vaginal portion of the cervix covers over the angle 



136 CARCINOMA OF THE UTERUS 

of the laceration nearly to the epithelium of the cervical 
canal. 

The most probable explanation of the greater frequency 
of carcinoma of the cervix uteri in the anterior or posterior 
lip of the cervix, than at the sides in the laceration, is 
the more frequent occurrence of erosions in the former 
places, and that unhealed erosions predispose to car- 
cinoma more than scar tissue. In other words, a laceration 
of the cervix uteri predisposes to the formation of a car- 
cinoma not on account of the scar tissue, but of the erosions 
which are formed. If this were not the case, there would 
be nothing gained in the prevention of carcinoma of the 
cervix by repairing lacerations. The repair of a laceration 
of the cervix cures the erosion, but scar issue will still 
remain as there is some cicatricial tissue as the result 
of the repair. 

Erosions. — These may result from lacerations of the 
cervix, as has been described, or from cervical inflammation 
and possibly from displacements of the uterus. It is not 
possible to state positively that carcinoma of the cervix 
ever starts as the result of an erosion. Many observers 
state that they have never seen such a case. Certainly, 
there are many cases of erosions of the cervix that have 
remained benign for years. 

By analogy with similar conditions in other parts of the 
body, it is fair to assume, however, that a carcinoma of 
the cervix uteri may be caused by a cervical erosion. 
An erosion is a lesion which is slow to heal, located at 
the junction of flat and cuboidal epithelium, and exposed 
to irritation. These are conditions generally believed to 
predispose to the development of cancer. Nothing more 
definite can be stated in regard to the relation between 
an erosion of the cervix and carcinoma. 

Cervical Inflammation. — The influence of cervical in- 
flammation in the causation of carcinoma of the cervix 
is both direct and indirect. 

It is generally believed that a chronic inflammation 
produces changes in the tissues that predispose to the 



PATHOLOGY 137 

formation of a malignant growth. Theilhaber strongly 
holds this belief. If this is true in other parts of the 
body it is probably also true in the cervix. 

The causation of carcinoma of the fundus uteri is less 
apparent than that of the cervix uteri. There are no 
apparent lesions, such as lacerations or erosions in the 
fundus uteri, that seem to have any influence in the 
formation of a carcinoma. It has been shown that car- 
cinoma of the fundus uteri is especially frequent in women 
who are sterile or who have had only one child, and that 
the average number of children in women who have 
carcinoma of the fundus uteri is less than usual. It is 
hardly possible that sterility itself in any way would 
increase the chances of the development of a malignant 
growth in the uterus. It is more natural to seek for a 
cause which might be responsible for the sterility and 
also for the carcinoma. A uterine polyp is probably 
such a lesion. Cases are recorded in which the carcinoma 
of the fundus uteri apparently started in a polyp. Such 
growths in other parts of the body are believed to predis- 
pose to the formation of carcinoma and might likewise 
do so in the uterus. Such a lesion could cause the sterility. 
It is possible that a narrow cervical canal, or a sharp 
angle of flexion, by retaining menstrual discharge, might 
predispose to the formation of cancer as well as cause 
sterility. It is possible that a chronic endometritis might 
be a predisposing cause. 

Pathology. — Carcinoma of the Cervix Uteri. — Histologi- 
cally there are two types of carcinoma of the cervix 
uteri, namely, the squamous-celled and the columnar- 
celled. The former usually begins in the flat epithelium 
of the vaginal portion of the cervix, especially at its 
junction with the cervical canal. The latter ordinarily 
starts from the columnar cells of the cervical canal or 
the glands leading to it. Clinically it is usually impossible 
to distinguish the histological varieties. 

Ilertzlcr, for the sake of greater clearness of descrip- 
tion, divides carcinoma of the cervix into three stages: 



138 CARCINOMA OF THE UTERUS 

(1) where the disease is limited to the cervix; (2) where 
the growth has extended to the parametrium, but the 
uterus is still movable, and (3) where the disease has 
extended to the parametrium and possibly also involved 
one of the neighboring organs and fixed the uterus. 
One stage, of course, merges directly into the next, but 
this division is convenient for descriptive and also for 
clinical purposes. 

First Stage. — There is an early stage when the car- 
cinoma is a small nodule or diffuse infiltration of the 
cervix. This stage, however, is rarely seen clinically, 
but is discovered microscopically in a cervix removed 
for other reasons. The earliest stage ordinarily seen 
clinically is the formation of small elevations or projections 
from the cervix, which on account of its appearance 
is often described as a cauliflower growth. This cauli- 
flower mass by rapid growth may reach a considerable 
size with a relatively small attachment to the cervix — 
a polypoid growth. Usually as this mass increases in size, 
its attachment to the cervix also increases, and ulti- 
mately involves the whole of the cervix. At some stage 
this mass breaks down and forms an ulceration. In 
some cases the ulceration forms early, so that at no time 
is a cauliflower growth seen. Most frequently the two 
processes are present together. Around the edges there 
is an abundant cauliflower growth with sloughing and 
ulceration in the centre. These are the two clinical 
varieties, the polypoid or cauliflower growth and the 
ulcerative. They are both a part of the same process, 
the ulceration being a later stage than the cauliflower 
growth. Cases that are seen in the first stage are favor- 
able for operation, and the outlook for a permanent cure 
is favorable. 

Second Stage. — In this stage the growth extends outside 
of the cervix and involves the cellular tissue of the para- 
metrium, but not to an extent to make the uterus im- 
movable. This involvement is partly by direct extension 
and partly through the lymphatic system. The extension 



PATHOLOGY 13.9 

of the growth is mostly to the sides, in the cellular tissue 
of the broad ligaments, and more rarely toward the bladder 
or rectum. There may also be extension upward into 
the fundus uteri or downward onto the vaginal walls. 
This extension into the uterus or onto the vaginal wall 
does not limit the mobility of the uterus nor influence 
the operability of the case as much as the lateral extension 
into the cellular tissue of the broad ligaments. The 
extension outside of the uterus does not usually occur 
until the cervix is partly destroyed by the ulcerative 
process of the first stage of the disease, and as a result of 
this septic process, a part of the induration around the 
uterus may be of an inflammatory character. Cases in 
the second stage are usually operable, but the outcome is 
distinctly less favorable than in those in which the growth 
,is limited to the cervix uteri. 

Third Stage. — In this stage, the lateral progress of the 
growth has usually extended into one or both broad 
ligaments and fixed the uterus in the pelvis. The normal 
mobility of the uterus is no longer present. The extension 
of the growth to the front and to the back is present but 
less marked than that to the sides. The growth may 
extend from the cervix uteri on to the anterior or posterior 
vaginal wall, and through the rectal or bladder wall as 
shown by proctoscopic or cystoscopic examination; but 
it is the exceptional case, even in the terminal stage, 
in which there is an ulceration into either of these organs 
forming a vesicovaginal or a rectovaginal fistula. 

The ureter is directly involved in the disease only in the 
late stage. Even though the growth has extended into 
the pelvic cellular tissue and entirely surrounded it, the 
wall of the ureter may not be involved. More frequently, 
on account of the pressure of the growth, there is an ob- 
struction of the ureter producing a hydro-ureter. As a 
result of this same obstruction a distention of the pelvis 
of the kidney may occur and a hydronephrosis may be 
produced. By infection a more advanced stage of the 
same process may be reached and the hydronephrosis 



140 CARCINOMA OF THE UTERUS 

converted into a pyonephrosis. Changes in the ureter 
and the kidney are among the most frequent terminal 
complications of carcinoma of the cervix uteri. 

By obstruction to the uterine canal, there may be 
interference with proper drainage of the fundus and a 
pyometrium produced. This is not usually of large size, 
as the obstruction is due to surfaces of the growth coming 
in contact and not to an organized stricture, and pressure 
of the accumulated discharge or sloughing of the growth 
overcomes it. 

In the end, as a result of the extension of the disease, 
the pelvis is filled with the malignant growth and the 
uterus is fixed on all sides. On vaginal examination, 
in addition to the ulcerated cervix uteri, the parts are 
found to be hard, rigid, and indurated, and not soft and 
pliable as under normal conditions. 

These cases are practically all inoperable. Any case 
of carcinoma of the cervix uteri, with the uterus fixed 
by the extension of the malignant growth, is beyond the 
reach of permanent benefit from present surgical technique. 
Palliative operations, as described elsewhere, may be 
indicated to control the symptoms. 

Metastases. — These occur late both in the lymphatic 
glands and in the distant organs. This fact adds greatly 
to the success of the operation for carcinoma of the 
cervix uteri. 

The lymphatic glands that are first involved are the 
one located at the crossing of the uterine artery and the 
ureter and those along the iliac vessels. More rarely 
a gland in the sacro-iliac ligament, the superficial and 
deep inguinal glands, and those higher in the abdominal 
cavity are involved. Enlarged glands are not necessarily 
carcinomatous. They may be enlarged as a result of 
the septic condition of the cervix or from some entirely 
separate process, such as a tuberculous infection. Involve- 
ment of lymphatic glands indicates a bad prognosis as 
to a permanent cure. Wertheim, Sampson and others, 
however, have reported cases of carcinoma of the cervix 



METASTASES 141 

uteri in which carcinomatous glands have been removed 
and the case remain well beyond the five-year period. 

Metastases in distant organs occur more frequently 
and at a later period than in the lymph nodes. 

The vagina may be involved by direct extension, 
and in most cases in which the growth has extended beyond 
the cervix uteri it has encroached on the vaginal wall 
at some point. More rarely the vaginal wall may be 
involved by direct contact with the cervical growth. 
In such cases a malignant ulcer is present in the vaginal 
wall entirely separated by normal tissue from the primary 
growth. It has been doubted that a contact cancer in 
the vagina can result from a carcinoma of the cervix 
uteri, and these cases are explained by retrograde metas- 
tases. It is not probable that cancer cells, under the 
septic conditions existing in the vicinity of a cervical 
carcinoma, can be engrafted on normal vaginal mucous 
membrane. If, however, a benign ulceration is first 
produced by the irritation of the growth it is more probable 
that cancer cells might become engrafted on it and the 
contact cancer be developed. A secondary growth in the 
vagina does not usually interfere with the operability 
of the case. 

The fundus of the uterus may be involved secondarily 
from a carcinoma of the cervix uteri. By direct extension 
the cervical growth may extend along the uterine mucous 
membrane and involve the whole or the greater part of 
the uterine cavity. 

In other cases the growth in the fundus may be separated 
from that of the cervix by an area that is apparently 
normal. The most probable explanation of this condition 
is that the growth in the fundus occurs by metastases 
Iron i that of the cervix through the lymphatic vessels. 
Cullen lias shown that there may be numerous micro- 
scopic growths secondary to a cervical carcinoma in a 
uterine fundus that microscopically seems normal. These 
growths may he on the mucous membrane or deeper in 
the uterine structure. 



U2 CARCINOMA OF THE UTERUS 

Carcinoma of the Fundus Uteri. — In the earliest stage 
adenocarcinoma of the body of the uterus is a limited 
circumscribed growth and may begin at any point in the 
cavity of the uterus. This tumor, as it increases in size, 
may remain localized or it may quickly spread, forming a 
diffuse growth. There may be, therefore, in the body of 
the uterus at an early stage a localized or diffuse adeno- 
carcinoma. In the earliest stage the character of the 
mucous membrane is so little changed that it can be dis- 
tinguished from the normal only by microscopic exami- 
nation. Later it becomes thickened and elevated with 
the formation of delicate processes or outgrowths. The 
formation of these processes takes place toward the cavity 
of the uterus, and also toward the deeper structures. In 
some cases the tumor grows largely toward the cavity 
of the uterus, filling it with the malignant growth, and in 
other cases it extends more toward the deeper tissues of the 
uterus. This may be due to special characteristics of the 
individual growth or to special resistance of the uterus. 
In the late stage these differences are not noticed, and 
not only is the cavity filled with the malignant growth, 
but the wall of the uterus is also entirely infiltrated 
with it. 

The malignant tissue is soft and friable and easily 
breaks down. The malignant infiltration of the uterine 
walls makes it much softer than normal. Clinically 
this may be detected by a bimanual examination or with 
the curette. These cases should not be curetted excepting 
when necessary to make a diagnosis, on account of the 
danger of cancer cells entering the normal tissues. Not 
infrequently there is no other way to make a correct 
diagnosis. In curetting an advanced case of carcinoma of 
the fundus uteri, a larger amount of tissue is removed 
than in an ordinary case of endometritis. Ordinarily 
in curetting after a part of the endometrium has been 
removed the uterus feels firm to the curette, but it is 
not so with a carcinoma of the body of the uterus that 
has passed the earliest stages. In such a case the uterine 



EXTENSION 143 

wall has become softened to such an extent that it is 
easily removed in pieces with a curette. In an extreme 
case the uterus is converted into a shell of muscular tissue 
and peritoneum enclosing a malignant growth. Special 
care must be taken to cease curetting as soon as the 
diagnosis is made or suspected. 

Extension. — When the growth reaches the peritoneum, 
elevations will appear on the surface of the uterus. At 
first these are small and separate, but later they grow 
together and may change the contour of the uterus. At 
first these elevations of malignant tissue are covered with 
peritoneum. Later it breaks through the peritoneum 
and may form adhesions to the intestines and omentum, 
which may become secondarily involved, or it may cause 
general peritoneal carcinomatosis. 

Extension to the pelvic connective tissue, for anatomical 
reasons, occurs later than in carcinoma of the cervix 
uteri. When a carcinoma of the cervix uteri reaches the 
outside of the uterus it comes directly to the connective 
tissue at the bases of the broad ligaments. A carcinoma 
of the fundus uteri when it reaches the surface comes to 
the peritoneum except at the sides where it is supported 
by the broad ligaments. 

As a tumor in the fundus uteri may be secondary 
to the cervical carcinoma, so also are reported tumors 
in the cervix and vagina secondary to a growth in the 
fundus uteri. One explanation of the formation of these 
secondary growths is that there has been a back flow in 
the lymphatic vessels and the cancer cells have been 
carried with it. Another explanation that has been made 
is that the pieces of cancerous tissue from the primary 
growth have become implanted on the mucous membrane 
of the cervix or on the vaginal wall. In support of the 
hitler explanation of the occurrence of these secondary 
growths is their location most frequently on the posterior 
vaginal wall where, theoretically, they would be most 
likely to occur. The formation of a secondary growth in 
this manner and under such circumstances would be very 



144 CARCINOMA OF THE UTERUS 

unusual if it ever occurred. A third possibility is that 
the cervical carcinoma was the primary growth and that 
in the fundus was a metastasis. 

Symptoms. — For greater clearness of description the 
symptoms of carcinoma of the cervix and fundus uteri 
will be given separately. 

Carcinoma of the Cervix Uteri. — The symptoms, as 
was done with the pathology, will be described for three 
stages, though the division is artificial and symptomatic- 
ally as well as pathologically no such division exists. 

First Stage. — Subjective Symptoms. — There are cases of 
carcinoma of the cervix uteri that give no subjective 
symptoms during the first stage. Theoretically this 
seems hardly possible, but clinically there is occasionally a 
case in which the growth has extended beyond the cervix 
before there were any symptoms that were noticed by the 
patient. There are two symptoms which are in practically 
all cases the first subjective symptoms of carcinoma of 
the cervix uteri. They are: (1) change in the mestruation 
or bleeding from the vagina, and (2) change in the vaginal 
discharge. Irregular bleeding and a change in the vaginal 
discharge are symptoms which should always raise the 
suspicion of a malignant uterine growth. They are 
usually the only subjective symptoms at the time the 
patient first seeks advice. 

1. Bleeding. — This symptom is of special significance 
when it occurs after the menopause. When there is a 
return of blood or a bloody discharge after the menstrua- 
tion has ceased, a uterine cancer is the most frequent cause. 
Frequently the first indication is bleeding following 
intercourse, a vaginal douche, or any other traumatism. 
The reason for this is obvious. The growth is mechanic- 
ally injured and the bleeding is the result of the trauma. 
The bleeding may first be noticed after straining to move 
the bowels. In such cases the patient may be deceived 
in regard to the source of the bleeding and think that it is 
due to hemorrhoids. The amount of bleeding may be a 
" spotting" or slight staining between the regular menstrual 



SYMPTOMS 145 

periods, or rarely, however, in the early stage enough to 
endanger the life of the patient. In other cases, especially 
in carcinoma of the scirrhus type, there may be no bleed- 
ing at all. 

2. Change in the Vaginal Discharge. — Most women have 
a slight vaginal discharge, which should not be considered 
abnormal. Some women have considerable discharge, 
and if it has existed for some years it is doubtless 
due to some other cause than carcinoma of the cervix 
uteri. If, however, a woman who has had no discharge 
begins to have one, or if the discharge which has existed 
for some time changes in character or amount, there should 
be a suspicion of carcinoma of the cervix uteri. In this 
first stage, it is the change in the character or in the 
amount of the discharge which is the suspicious symptom, 
more than the discharge itself. The discharge is usually 
thin and watery, more or less discolored with blood, and 
of a characteristic odor. 

3. Pain. — This symptom is usually absent during this 
early stage. If present, it is probably due to inflammatory 
conditions about the uterus or to other pelvic lesions 
and not to the cervical cancer. 

4. General Health. — This is not changed. There is 
loss of neither flesh nor strength. 

First Stage, Physical Signs. — The cervix may show an 
erosion or contain a nodule the nature of which is dis- 
covered only by microscopic examination. These very 
early cases are rarely seen. Usually there is a cauliflower 
growth or an ulceration in the cervix. The characteristic 
feeling, which is one of dense hardness, is of greater 
diagnostic value than the appearance of the ulceration 
and is usually sufficient to establish the diagnosis. The 
statement that "the doubtful case is rarely malignant" is 
true. 

In this stage there are no objective signs other than 
those of the cervix just described. The uterus is not 
changed materially in size, position, or mobility. 

It is possible to give only an indefinite estimate of the 

10 



146 CARCINOMA OF THE UTERUS 

duration of the first stage. It is usually under four months 
from the beginning of the first symptoms. 

Second Stage, Subjective Symptoms. — 1. Bleeding. — 
Though it may be absent, bleeding is more constant than 
it is in the first stage, and retains the same general char- 
acteristics, such as "spotting" between regular menstrua- 
tions, increased in amount by intercourse, injury, etc. 
Profuse bleeding resulting from ulceration of an artery or 
from a digital examination is a more frequent occurrence 
than in the earlier stage. 

2. Discharge. — This is usually at this period a char- 
acteristic symptom. The discharge is thin and watery 
and has an odor which is peculiar to the disease. Frequent 
douches will not entirely control the discharge or the odor. 

3. Urinary Symptoms. — Extension of the cervical 
carcinoma to the anterior vaginal wall and to the bladder 
may occur during this stage. Increase in frequency and 
painful urination are frequent symptoms. These symp- 
toms do not necessarily mean that the bladder wall itself 
is involved by the growth. It may be the result of an 
inflammatory reaction in the bladder from the ulcerated 
cervix. The bladder often may be separated successfully 
from the anterior vaginal wall even if the latter is involved 
by the malignant growth. 

4. Rectal Symptoms. — These are ordinarily absent 
during this stage. Anatomically, the rectum is less closely 
related to the cervix uteri than the bladder. The growth 
may have extended on to the posterior vaginal wall and 
still be separated from the rectum by the cul-de-sac 
of Douglas. 

5. Pain. — This symptom is usually present during 
this stage. It may be due to the involvement or pressure 
on the nerves by the growth or to the inflammation of the 
tissues about the uterus. The pain may be referred to 
the back, to the lower abdomen on either or both sides, 
or down either or both legs. 

6. General Health. — There is a beginning loss of flesh 
and strength, and the patient shows the early general 



SYMPTOMS 147 

signs of a malignant growth. It is not possible to give 
the period of time of this second stage in a definite way. 
Roughly, it occurs from the fourth to the eighth month 
from the first symptoms. Rarely is a case that has lasted 
over eight months operable. 

Second Stage, Physical Signs. — The cervix is largely 
destroyed by an ulceration. The vaginal wall, especially 
to the front of the cervix, may also be ulcerated. On one 
or both sides of the cervix there is an infiltration of the 
broad ligaments. The mobility of the uterus may be 
decreased. There is usually no material change in the 
size of the uterus. 

Third Stage, Subjective Symptoms. — (1) Bleeding and 
(2) discharge are the same as during the second stage. 
Pain on account of the extension of the disease is a more 
constant symptom and is more severe. Pain is distinctly 
increased if the peritoneum becomes involved. 

3. Rectal Symptoms. — There may be increasing con- 
stipation. This may be caused by definite obstruction 
due to the rectal involvement by the growth, or it may 
be due to the pain produced by the passage of feces over 
the growth. If a rectovaginal fistula is formed, the 
feces may be passed through the vagina. 

4. Urinary Symptoms. — There may be pain and in- 
creased frequency of urination. The urine may contain 
pus, blood, and mucus, indicating that the growth has 
involved the bladder wall. The urine may flow into the 
vagina if a vesicovaginal fistula is formed. The symptoms of 
pyelitis, hydronephrosis and pyonephrosis may be present. 

5. General Condition. — There is the general loss of flesh 
and strength common to the terminal stages of all malig- 
nant growths. Metastases may form in the liver, lungs, 
or kidneys, but usually only during the latest stages of the 
disease. There may be a general septic infection due to 
absorption from the ulcerated cervix. The loss of blood 
may produce a profound secondary anemia. 

Third Stage, Objective Signs. — The uterus is not 
increased materially in size, but it is firmly fixed in the 



148 CARCINOMA OF THE UTERUS 

pelvis. The cervix uteri may be entirely destroyed by 
the ulceration and the examining finger may pass into the 
cavity of the uterus without meeting any obstruction. 
There is a deep excavation lined with irregular necrotic 
tissue. The vagina may be ulcerated only at the upper 
part or the malignant infiltration may extend down as 
far as the vulva. It may communicate directly by a 
fistula with the bladder or the rectum. On either side of 
the uterus the malignant infiltration of the broad liga- 
ments can be felt. The bladder may, by cystoscopic 
examination, be found to contain a malignant growth or 
ulceration. Similar involvement of the rectum may be 
discovered by proctoscopic or digital examination. The 
inguinal glands may be found enlarged. 

Carcinoma of the Fundus Uteri. — Subjective Symptoms. — 
The two first symptoms of carcinoma of the fundus 
uteri are the same as those of the cervix uteri. They are: 
(1) irregular bleeding and (2) change in the vaginal dis- 
charge. 

1. Bleeding. — This may be absent until the disease is 
well advanced. If the patient is still menstruating, there 
may be only an increase in the duration, amount or 
frequency of the menstruation. The most frequent 
history is that after a period of some years of absence of 
menstruation (carcinoma of the fundus uteri is most 
frequent at an advanced age) there is a return of bleeding 
which is irregular in amount and in time. 

There are cases which are undoubtedly carcinomata of 
the fundus uteri which give a history of bleeding extending 
back over a period of years. It is incorrect to assume 
that the malignant growth has always existed as long as 
the irregular bleeding. The irregular bleeding may have 
been due to an endometritis, a fibroma uteri, a uterine 
polyp or some other cause and the malignant growth 
a subsequent development. The bleeding of carcinoma 
of the fundus uteri is not influenced by trauma to the same 
extent as cervical carcinoma. 



CARCINOMA OF THE FUNDUS UTERI 149 

2. Change in the Vaginal Discharge.- — This symptom 
is more constant and is usually earlier than the irregular 
bleeding. The discharge is usually thin and watery. In 
the early stages, the odor of the discharge is not enough 
to be noticed by the patient or on the examining fingers, 
but at a later stage it is more marked. The discharge 
may contain pieces of malignant tissue but only at an 
advanced stage of the disease at which other symptoms 
easily establish the diagnosis. 

3. Pain. — As in cancer elsewhere this is not an early 
symptom of carcinoma of the fundus uteri, and may not 
be a marked symptom at any stage of the disease. There 
is probably less pain on an average with carcinoma of the 
fundus uteri than with most cancer. The explanation 
of this is twofold. The uterus relatively is an insensitive 
organ, and is well protected from outside injury, and a 
growth in it may reach considerable size without involving 
any sensitive part. 

With the exception of menstruation and child-bearing 
the uterus has no special function, and on account of the 
age of the patient and the nature of the disease both of 
these functions may have ceased. In the stomach the 
intestines, the rectum, the tongue, etc., a carcinoma is 
constantly irritated and injured by the movements and 
use of the organs. It is different with a carcinoma of 
the fundus uteri, an organ which is quiescent and protected 
from injury. 

At an advanced stage there may be paroxysms of pain 
as though the uterus were attempting to expel a foreign 
body from the cavity. Such pain is usually relieved by 
a curettage. A curettage is, however, not ordinarily 
performed for carcinoma of the fundus uteri excepting 
for diagnostic purposes. 

When the growth has extended through the wall of the 
uterus and involved the peritoneum there is usually con- 
siderable abdominal pain, but even when the peritoneum 
is involved the pain may not be severe. If the uterus is 



150 CARCINOMA OF THE UTERUS 

increased in size there may be a sense of pressure and 
falling from its weight. 

4. Urinary Symptoms. — These are not present in the 
early stages, but later there may be symptoms of vesical 
irritation. This may be the result of pressure or the 
dragging of the heavy uterus or of the involvement of the 
bladder by the growth. 

5. General Condition.— Carcinoma of the fundus uteri 
does not involve an organ whose function is to support 
the nutrition or general vitality of the organism. The 
bleeding from it does not cause the secondary blood 
changes as early as does carcinoma of the cervix uteri. 
Metastases occur only late in the disease. Frequently 
the disease has reached the inoperable stage before the 
general liealth is affected with more than a moderate 
secondary anemia. 

Objective Signs. — The one sign of importance is the size 
of the uterus. It must be remembered that most cases 
of carcinoma of the fundus uteri occur in women well 
passed the menopause and that the uterus in such cases 
is atrophic and under normal size, that is, it is a senile 
uterus. When a carcinoma of the fundus uteri has 
advanced sufficiently to give any subjective symptoms, 
that is, either bleeding or discharge, the uterus is nearly 
always of at least normal size — it is larger than a senile 
uterus. Reversely, an atrophic uterus, the small senile 
uterus, is rarely the seat of a malignant growth. 

As the disease advances the uterus increases in size. 
It rarely reaches a size which is larger than the uterus 
of a two or three months' pregnancy. 

The consistency in the early stages is that of a normal 
uterus. Later the uterus is soft and flabby. The cervix 
is usually not changed; it may be open. This is the 
condition if the tumor grows through the cervical canal 
or the uterus attempts to expel it. 

Diagnosis. — There are three conditions from which a 
carcinoma of the fundus uteri must be distinguished: 



COURSE 151 

1. A submucous fibroma uteri, if of small size so that 
the uterus is only moderately and symmetrically increased 
in size, may closely simulate a carcinoma of the fundus 
uteri. A curettage usually is necessary to establish 
the diagnosis. The discovery of the fibroma in the uterus 
and the microscopic examination of the tissue removed 
will decide the diagnosis. 

2. Endometritis. — At the menopause an endometritis 
causing irregular bleeding and a vaginal discharge is a 
frequent occurrence. A curettage and a microscopic 
examination of the tissue removed is the only way to 
disinguish between an endometritis and an early carcinoma 
of the fundus uteri. This should be done under an anes- 
thetic and with an immediate microscopic examination 
of the tissue removed. 

In some of these cases the microscopic examination 
shows only a benign endometritis, but the irregular 
bleeding continues. Regardless of the microscopic 
examination, such cases should be considered suspicious 
and carefully watched. A second curettage or possibly 
a hysterectomy may be necessary. 

3. Senile Vaginitis. — This is a common lesion which 
gives symptoms closely resembling a carcinoma of the 
fundus uteri. A small atrophic uterus is against a car- 
cinoma of the fundus. The recognition of the senile 
vaginitis, and its cure by proper treatment, will definitely 
establish the diagnosis. 

Course. — It is difficult to correctly estimate the average 
duration of carcinoma of either the cervix or the fundus 
uteri because it is impossible in most cases to determine 
the beginning of the disease because of its gradual onset. 

In general, carcinoma of the cervix uteri runs a more 
rapid course than carcinoma of the fundus uteri. The 
duration of the former on the average is two to two 
■ ii id a half years and of the latter about a year longer. 
This difference in the duration of the disease in the two 
places may be due to the anatomical conditions. Car- 
cinoma <>t' the I'm id us uteri is protected from mechanical 



152 CARCINOMA OF THE UTERUS 

injury, frequent movement, and for a longer time from 
secondary infection. These conditions probably influence 
the spread of the disease. The relative duration of the 
disease in the two places is also influenced by the earlier 
involvement in carcinoma of the cervix of organs such 
as the rectum, bladder, and ureters which indirectly may 
shorten the duration of the disease. 

The duration of carcinoma of the cervix uteri may be 
prolonged by proper treatment, even if the case is in- 
operable. The cervical discharge and bleeding and the 
secondary infection may be limited as described elsewhere. 

Treatment. — This will be considered under three head- 
ings: (1) diagnosis, (2) operable cases, and (3) inoperable 
cases. 

1. Diagnosis. — Carcinoma of the cervix uteri can 
usually be diagnosed by the appearance and feeling of 
the cervix. A piece of the growth should not be removed 
for microscopic examination, excepting in the doubtful 
cases, because of the danger of scattering cancer cells 
beyond the uterus. For the same reason, unnecessary 
or too thorough examination of carcinoma of either the 
cervix or fundus uteri should be avoided. Any pieces 
of the cervix uteri which are removed for any purpose 
should always be subjected to microscopic examination 
in order to discover the early and unsuspected cases. 

Carcinoma of the fundus uteri can usually be diagnosed 
only by a curettage. It is therefore necessary to curette 
into malignant tissue to establish this diagnosis regardless 
of the danger of scattering cancer cells. As soon as the 
diagnosis is established (as can be done in some cases with 
the curette without further examination), or sufficient 
material has been removed for a frozen section for a 
microscopic examination, no further curetting should 
be done in order to limit this danger as much as possible. 
In every case that is curetted, whether carcinoma is 
suspected or not, the curettings should be examined 
microscopically in order to discover early and unsuspected 



TREATMENT 153 

2. Operable Cases. — Under this heading are included 
the cases of carcinoma uteri which are sufficiently limited, 
that the uterus can be removed with the expectation of 
curing or prolonging the life of the patient. Cases that 
are so far advanced that no operation other than a pallia- 
tive one, such as cauterization or a curetting for the relief 
of the symptoms, can be performed are not included. 
For the clearness of description, though it may require 
some repetition, carcinoma of the cervix uteri will be 
considered separately from carcinoma of the fundus uteri. 

Carcinoma of the Cervix Uteri. — Of the three stages 
into which the course of a carcinoma of the cervix uteri 
was artificially divided for the description of the symptoms, 
all the cases in the first stage, that is, the stage in which 
the disease is limited to the cervix uteri are operable. 
All the cases in the third stage, that is, the stage in which 
the growth has extended so far that the uterus is fixed 
in the pelvis are inoperable. Of the cases in the second 
stage, some are operable and some are not. In general, 
if the growth has not extended so far that the uterus is 
fixed, the case is operable. Usually if the growth outside 
of the uterus has extended not over an inch into the 
broad ligaments, and only moderately on to the vaginal 
walls the case would be benefited by the removal of the 
uterus and should be considered operable. These state- 
ments, however, should not be considered absolute, and 
the general condition of the patient, as well as the local 
lesion, must be considered. In a patient who is thin but 
in good general condition — in other words, one on whom 
the operation would be relatively easy and who would 
be a favorable operative risk — a more extensive car- 
cinoma of the cervix uteri would be considered operable 
than in a woman on whom the operation would be asso- 
ciated with greater risk. 

A carcinoma of the cervix uteri may be limited in extent 
and the case operable so far as the local lesion is con- 
cerned, but inoperable on account of metastases in other 
organs or in lymphatic glands. Frequently an exploratory 



154 CARCINOMA OF THE UTERUS 

celiotomy is necessary to determine the operability of the 
case. Only after the abdomen has been opened and the 
condition of the liver, intestines, peritoneum, omentum, 
and lymphatic glands, determined by direct inspection, 
can the operability of the case be decided. It may be 
necessary to remove a lymphatic gland for examination of a 
frozen section to determine the nature of its enlargement. 

After the abdomen has been opened, if metastases are 
found in abdominal organs the case is inoperable and 
usually the uterus should not be removed. There are, 
however, some cases with metastases in which the removal 
of the uterus is indicated. If the general and local con- 
ditions of the patient are such that a hysterectomy can 
be done without special risk it should be done. The 
removal of the uterus, with the infected sloughing growth 
in the vagina and the control of the bleeding and foul 
discharge, will add to the mental and physical comfort of 
the patient even if her life is not prolonged. 

Involvement of the lymphatic glands that are accessible 
is not a contra-indication to removal of the uterus though 
it diminishes the chances of a permanent cure. 

Carcinoma of the Fundus Uteri. — An exploratory celi- 
otomy is necessary more often for cases of carcinoma of 
the fundus uteri than of the cervix uteri. If the growth 
has extended through the wall of the uterus and involved 
the peritoneum there will probably be multiple peritoneal 
growths in other parts of the abdomen and adhesions to 
the viscera, and the case is incurable. As with cases of 
cervical carcinoma, as the abdomen is already open, if 
the local and general conditions are such that the uterus 
can be removed without special risk, a hysterectomy should 
be performed to cure the discharge and bleeding. This will 
add greatly to the comfort of the patient and may tem- 
porarily improve the general health, but will, of course, 
not cure the condition. 

Carcinoma of the fundus uteri remains operable for a 
longer time after the first symptoms than carcinoma of 
the cervix uteri. 



TREATMENT 155 

Percentage of Operability. — There are no statistics from 
which any close estimate can be made of the percent- 
age of cases of carcinoma of the cervix uteri which are 
seen to be still operable. Such a percentage would vary 
greatly for the same cases with different operators. 
Some men knowing that the removal of the uterus is 
practically the patient's only hope will assume a higher 
operative risk for a smaller chance of permanent cure 
than others. 

There is a direct relationship between the percentage 
of operability, of operative mortality, and of the per- 
manent cures. The surgeon who has a high percentage 
of operability, that is, who operates on the more exten- 
sive cases, has a higher percentage of deaths from the 
operation and a lower percentage of permanent cures 
than the man who operates only on more favorable cases. 
By operating on the extensive cases, however, there is a 
larger absolute number of permanent cures because some 
cases are saved that otherwise would be lost. In some 
European clinics as high as 78 per cent, operability is 
reported; the average for all clinics, however, is probably 
not over 40 per cent. In America the percentage of opera- 
bility is still less. In a series of about 80 cases reported 
to the health department of a large American city as 
having died of carcinoma of the uterus, only 25 per cent, 
had had an operation for the cure of the lesion. In the 
whole country the percentage would be much less. 

Operation. — For the operable case of carcinoma of the 
cervix uteri, as it has been defined under this heading, 
the removal of the uterus is the operation which promises 
the best immediate and permanent result to the patient 
and is therefore indicated. The removal of the uterus is 
done either by the abdominal or vaginal route. By each 
route there are two general methods depending on the 
amount of cellular tissue that is removed. These opera- 
tions are usually designated as "simple" and "radical" 
hysterectomies. Thai is, the operations for carcinoma 
of the cervix or fundus uteri arc: 



156 CARCINOMA OF THE UTERUS 

1. Radical abdominal hysterectomy. 

2. Simple abdominal hysterectomy. 

3. Radical vaginal hysterectomy. 

4. Simple vaginal hysterectomy. 

A radical abdominal hysterectomy is the removal of 
the uterus and the appendages together with as much as 
possible of the pelvic connective tissue and also the 
iliac glands. The operation is frequently designated 
as Wertheim's operation, though the general principles 
were first described by Clark and Ries. The operation 
is extensive, necessitating the exposure of the ureter on 
each side, and is associated with a high operative mortality 
ranging from 10 per cent, to 25 per cent. This operation 
should be done for carcinoma of the cervix uteri only in 
cases that are favorable surgical risks; it should not be 
done on patients with cardiac, pulmonary, renal, or other 
general lesions which in themselves would add to the 
risk of the operation. A thick abdominal wall adds to 
the difficulty of the operation, and may contra-indicate 
it on account of the increased risk. 

The radical abdominal hysterectomy is the operation 
of first choice for carcinoma of the cervix uteri. 

The radical abdominal hysterectomy should be per- 
formed for carcinoma of the fundus uteri only in exception- 
ally favorable cases if at all. A carcinoma of the cervix 
uteri extends comparatively early to the cellular tissue 
about the cervix uteri, and it is the removal of this cellular 
tissue that is accomplished by the radical operation and for 
which the high operative risk is assumed. A carcinoma 
of the fundus uteri extends toward its peritoneal coat 
and does not involve the pelvic cellular tissue until late. 
In most cases there is probably an involvement of the 
peritoneum and some abdominal viscera before there is 
an extension into the broad ligaments. The advantage 
gained, therefore, by the radical operation is not sufficient 
to warrant the greater operative mortality. 

The simple abdominal hysterectomy is the removal 
of the uterus and the appendages, but without any 



TREATMENT 157 

definite attempt to remove any of the pelvic connective 
tissue. The operation is indicated in cases of carcinoma 
of the cervix uteri which are unfavorable for the radical 
abdominal operation and for practically all operable 
cases of carcinoma of the fundus uteri. The operation 
is easier than the radical operation, and is associated 
with a much lower operative mortality. 

As no attempt is made to remove any of the pelvic 
cellular tissue around the cervix the operation is prac- 
tically limited to those cases in which there has been 
little or no involvement of the broad ligaments. In 
other words, many cases of carcinoma of the cervix 
uteri are operable only by a radical operation. 

In a radical vaginal hysterectomy the vagina is enlarged 
by a paravaginal incision, and the uterus and appendages 
with a liberal amount of cellular tissue are removed. 
The operation is one that is rarely performed in America. 
Its strongest advocate is Schauta, of Vienna. The 
chief advantage claimed for the operation is a lower 
primary mortality than from the radical abdominal opera- 
tion. A disadvantage claimed for it is that the iliac 
lymphatic glands cannot be examined and removed if 
found diseased. 

A simple vaginal hysterectomy was formerly the 
usual operation for a carcinoma of either the cervix or 
fundus uteri. It is associated with a low primary mortality, 
but with a greater risk of scattering cancer cells during 
the manipulation of the uterus and of the implantation 
of cancer cells in the vaginal wound during the operation. 
It is the operation to be selected in a patient with a thick 
abdominal wall and a large vagina or with a prolapse of 
the uterus. 

:;. Inoperable Cases. — Probably 75 per cent, at 
least of the cases of carcinoma of the cervix uteri and 
of the fundus uteri are inoperable at the time that they 
are seen by competent surgeons; that is, they have 
passed the stage when the uterus can be removed with 
any hope of permanently curing the patient. Fnfortu- 



158 CARCINOMA OF THE UTERUS 

nately on account of local recurrences a large part of the 
cases that are subjected to operation are ultimately in 
this same inoperable class. While there may be no hope 
of permanently benefiting these cases, their lives can 
be prolonged and made far more comfortable by ap- 
propriate treatment. The irregular bleeding and the 
foul discharge can often be controlled so that they are 
not troublesome symptoms even during the terminal 
stages of the disease. 

Cauterization. — This is by far the best treatment for 
an inoperable carcinoma of the cervix uteri. It is appli- 
cable to the early stage of inoperable cases. There is 
little or nothing to be gained by cauterizing the advanced 
stage after the vaginal walls have been largely involved 
or there has been an ulceration into either the vagina 
or the rectum. 

The use of the cautery in the treatment of carcinoma 
of the cervix uteri was strongly advocated by Byrne, of 
Brooklyn; about 1892. He used it in the early as well as 
in the more advanced cases, and his end-results compare 
favorably with most operative results at the present time. 
More recently Percy has perfected Byrne's technique 
principally by the introduction of the hand of an assistant 
into the abdominal cavity to guide the operator in the 
use of the cautery. Byrne and also Percy urge that the 
cautery should not be at too high a degree of heat, as by 
a lower degree of heat and deeper penetration, cancer 
cells in tissue otherwise normal may be destroyed without 
permanent injury to the tissue itself. Percy advocates 
the use of the cautery for cases that most surgeons would 
consider suitable for a hysterectomy. He uses it not only 
as a palliative measure to relieve symptoms but also as a 
curative method. Most surgeons use the cautery alone 
on cases that are considered inoperable, or to sterilize the 
growth previous to its removal by operation. 

Caustics. — Chloride of zinc is the caustic most frequently 
used in the treatment of carcinoma of the cervix uteri. 
It may be used by applying pieces of cotton or gauze 



END RESULTS 159 

soaked in a solution of chloride of zinc to the cervix uteri 
after the friable portion of the growth has been removed 
with the curette. Repeated applications of the caustic 
are necessary. By controlling the bleeding and discharge 
the general health of the patient may be improved. 

Acetone has been recommended by Gellhorn for the 
treatment of inoperable carcinoma of the cervix uteri. 
The acetone is allowed to remain in contact with the 
malignant growth exposed by a speculum for five or more 
minutes, depending on the amount of pain caused by it. 
The result is to harden the tissue and to control the 
bleeding and discharge. Neither chloride of zinc nor 
acetone checks the spread of the disease. 

Douches. — Simple cleansing douches such as boric acid, 
salt solution, etc., add to the comfort of the patient 
by keeping the vagina and the malignant growth clean. 
If the discharges are not allowed to accumulate and de- 
compose in the vagina there is less odor. In general the 
odor is controlled better by keeping the parts clean 
than by the use of disinfectants. 

Pain. — Much can be accomplished for the pain of 
carcinoma of the cervix uteri by keeping the growth 
clean. The pain is often greatly relieved by a thorough 
curettage and cauterization of the growth. The pain in 
carcinoma of the fundus uteri may be due to pieces of 
tissue or discharge retained in the uterus, which act as 
foreign bodies causing uterine contractions. This pain 
is relieved by a curettage which will leave a uterus that 
is relatively clean and with free drainage. 

Sedatives are usually necessary during the inoperable 
stage. At first aspirin and phenacetin will control the 
pain. Later codeine and morphin will be necessary. 

End Results. — The end results of operations for car- 
cinoma of the cervix uteri as reported by different oper- 
ators show wide variations. With the more extended 
radical abdominal operation, there has been a definite 
increase in the percentage of cures even though more 
extensive cases are subjected to operation. 



100 CARCINOMA OF THE UTERUS 

The following table taken from Doderlein and Kronig's 
Operative Gynakologie gives the operability, the absolute 
and the relative cures for a number of European operators : 

RADICAL ABDOMINAL HYSTERECTOMIES. 



Operator. 


Operability. 
Per cent. 


Absolute cures. 
Per cent. 


Relative cures 
Per cent. 


Zweifel 


. . 51.8 


23.4 


45.2 


Doderlein 


. . 59.7 


17.0 


28.0 


Bumm 


. . 60.9 


16.0 


26.3 


Kronig 


. . 78.9 


25.3 


32.2 


Wertheim 


. . 56.0 


18.3 


42.4 


RADIC 


AL VAGINAL 


HYSTERECTOMIES. 


Operator. 


Operability. 
Per cent. 


Absolute cures. 
Per cent. 


Relative cures. 
Per cent. 


Schauta . 


. . 51.3 


16.4 


34.5 


Staude 


. . 70.7 


20.0 


30.0 


Thom . . . 


. . 44.2 


19.3 


43.7 



By "operability" is meant the percentage of cases that 
come under observation that are operated upon. "Ab- 
solute cures" are the percentage of cases that are seen, 
that are well at the end of the five-year period. " Relative 
cures" are the percentage of cases that are operated 
upon, that are well at the end of the five-year period. 

These figures represent the best results that are ob- 
tained in the large European clinics and are more favor- 
able than American results. In America the cases of 
carcinoma of the cervix uteri do not come under observa- 
tion until a more advanced stage than in Germany and 
Austria. The percentage of "relative" cures following the 
radical abdominal operation in America is under 15 per 
cent. The percentage of "relative cures" following the 
simple abdominal or vaginal hysterectomies is distinctly 
less than 10 per cent. This is an unfortunate showing 
for a disease, which, if recognized early could be cured in 
most cases. 

The end results of operations for carcinoma of the 
fundus uteri are by far more favorable than those of car- 



CAUSES OF DEATH FOLLOWING OPERATION 161 

cinoma of the cervix uteri. This is true of American as 
well as of European clinics. The following table, adapted 
from Doderlein and Kronig, gives the percentages of cures 
following operations for carcinoma of the fundus uteri, 
of a number of European operators: 

Olshausen 40 . per cent. 

Leopold 100.0 " 

Pfannenstiel 86.8 " 

Zweifel 77.7 

Kaltenbach 66.6 " 

Doderlein 100.0 

The reasons for these more favorable results have 
already been given. 

Causes of Death Following Operation. — Nearly one-half 
of the deaths following the radical abdominal operation 
for carcinoma of the cervix uteri are due to some form 
of sepsis. Of 93 deaths in Wertheim's series of 500 cases 
there were 39 deaths, or 42 per cent., from peritonitis. 
The source of the sepsis is the infected malignant growth 
in the cervix, which is practically impossible to com- 
pletely sterilize. 

There were twenty- two deaths, or 24 per cent., from 
feeble heart and cachexia. These deaths were probably 
due to the combination of causes which include bleeding, 
shock, anesthesia, etc., of a severe operation on a patient 
in poor general condition. The high percentage of deaths 
from these causes is indicative of the severity of a radical 
abdominal hysterectomy for carcinoma of the cervix 
uteri. 

There were nine deaths, or 10 per cent., from pyelo- 
nephritis. In this operation each ureter is exposed and 
the bladder is widely separated from the uterus and 
vagina. Retention of urine requiring catheterization for 
a long period is a frequent result. The pyelonephritis 
is the result of these three factors, the minute injury to 
the bladder and ureters and the prolonged use of the 
catheter. 

Among the other causes of death following the radical 
11 



162 CARCINOMA OF THE UTERUS 

abdominal hysterectomy for carcinoma of the cervix uteri 
as shown by Wertheim's series are ileus (3 cases), post- 
operative bleeding (2 cases), ligation of ureters (1 case), 
and pneumonia (2 cases). 

Recurrences. — Locality. — In addition to metastases in 
distant organs, which are comparatively rare, recurrences 
following the removal of the uterus for carcinoma of the 
cervix uteri are found in two places: (1) in the scar at 
the top of the vagina, or in the cellular tissue immediately 
around it, and (2) in the lymphatic glands. 

The largest number of recurrences are in the vaginal 
scar or in its immediate vicinity. There are two factors 
which influence the frequency of recurrence in this locality. 
The cellular tissue about the top of the vagina is that in 
which extension of a carcinoma of the cervix uteri regularly 
occurs and it is at this place that it is most difficult to 
work widely from the disease in removing the uterus. 
The other factor is the implantation of cancer cells in the 
cut edge of the vagina in the removal of the uterus. 
Great care should be used to avoid the implantation of 
cancer cells by destroying as much of the growth as possible 
with the cautery before beginning to remove the uterus. 
Some surgeons cut through the vaginal wall with the cau- 
tery for this same purpose. The prevention of recurrence 
in this vicinity is also favored by the removal of a wide 
cuff of vagina with the cervical growth. 

Recurrence in the lymphatic glands, following the 
removal of the uterus for carcinoma, is infrequent. The 
lymphatic glands in either carcinoma of the cervix uteri 
or of the fundus uteri are involved late and when the 
glands have become involved, the local lesion is usually 
so extensive that the case is inoperable. When the glands 
are involved, they are usually the iliac glands. In some 
cases it may be possible to feel them under an anesthestic. 

Types. — Clinically there are two distinct types of 
recurrence of carcinoma of the uterus — the diffuse and 
the circumscribed. The diffuse type is most frequent 
and the entire top of the vagina is infiltrated with the 



CARCINOMA UTERI AND PREGNANCY 163 

growth which is beyond further operative relief. The 
circumscribed is rare. There is a distinct circumscribed 
nodule which may be movable. The important point 
about this type of recurrence is that frequently it can be 
removed by another operation. There are some cases 
that have remained well permanently after the removal 
of such a recurrence. 

Time of Recurrence. — The following table, formed parti}' 
by statistics given by Doderlein and Kronig and partly 
from the report of Wertheim's cases, gives by years the 
percentage of recurrences of a number of operators following 
operations for carcinoma of the uterus : 

First Second Third Fourth Fifth 

year, year, year, year, year, 

per cent. per cent. per cent. per cent. per cent. 

Winter . . 77.0 9.0 9.0 3.4 1.3 

Seitz . . . 40.5 36.2 7.2 4.3 4.3 

Wertheim . 53.0 30.0 8.0 5.0 4.0 

Frommel . 36.6 

Zweifel . . 69.0 

Fritsch . . 77.0 

The percentages in this table give the years at which 
the recurrences were first noticed. The deaths would be 
at a later period. As shown by the table, the recurrences 
were most frequent the first year after operation, and after 
the second year comparatively infrequent. Recurrences 
may occur even after the fifth year. According to Doder- 
lein and Kronig, in Olshausen's Clinic, two recurrences 
occurred in the sixth year, one in the eighth, and one in 
the tenth year. 

CARCINOMA UTERI AND PREGNANCY. 

Frequency. — This, fortunately, is a rare combination, as it 
is associated with greatly increased risk to the mother and 
to the child. Sarwey from combined statistics reported 
its occurrence in 0.05 per cent, of cases of pregnancy. A 
factor in the infrequency of the combination of carcinoma 
of the uterus and pregnancy is that the cancer age and 
the child-bearing age overlap but do not coincide. Car- 



164 CARCINOMA OF THE UTERUS 

cinoma of the uterus is rare under thirty years of age and 
most frequent between thirty and fifty years. Child- 
bearing is most frequent between twenty years and forty 
years of age and relatively rare later. It is during the 
common decade between thirty-one and forty years of 
age, which is a period when child-bearing and carcinoma 
of the uterus are both frequent, that the greatest number 
of cases of carcinoma of the uterus and pregnancy occur. 
Sarwey, in a study of 73 cases, found 11 per cent, between 
the ages of twenty and thirty years and 22 per cent, 
between the ages of forty-one and fifty years. 

In regard to the occurrence of pregnancy with a car- 
cinoma of the uterus there are two possibilities: One is that 
the carcinoma started after the inception of the pregnancy, 
the other is that the carcinoma existed before the preg- 
nancy occurred. The consideration of these two possibili- 
ties must be largely on theoretical lines only. It is easy 
to understand that a carcinoma may start in the cervix 
uteri after a pregnancy has started. There is probably 
nothing in a pregnancy that prevents the development 
of a carcinoma, though such an idea formerly prevailed, 
and a carcinoma can develop during the months of preg- 
nancy as well as during any other like period of time. 
On account of the increased activity of the pregnant 
uterus the carcinoma would grow with unusual activity 
and might reach an advanced stage of growth during the 
period of pregnancy. 

It is probable that a pregnancy would not start after the 
beginning of a carcinoma of the uterus unless the malig- 
nant growth was in a very early stage, and it originated 
in the vaginal portion of the cervix, or in the cervical 
glands and did not involve the cervical canal. Later, 
when a cauliflower growth or an ulceration has developed 
on the cervix, an impregnation would seem to be practically 
impossible. 

Pregnancy with a carcinoma of the fundus uteri probably 
never occurs at all or progresses only a short period. 
An impregnated ovum would not find a suitable place for 



CARCINOMA UTERI AND PREGNANCY 165 

growth in the malignant tissue, and if it started in normal 
uterine mucosa beside the malignant growth the latter 
would soon displace it. There have been a few cases of 
pregnancy and a carcinoma of the fundus uteri reported 
in the literature, but it has been suggested that they were 
really cases of malignant deciduoma. 

Abortion. — Outcome of the Pregnancy. — The outcome of 
the pregnancy depends on the location of the carcinoma. 
If it is located on the vaginal portion of the cervix or in 
the lower part of the cervical canal the carcinoma probably 
does not influence the pregnancy. As the carcinoma 
increases in extent and approaches the cavity of the 
uterus an abortion is more likely to occur. Sarwey 
reports 30 to 40 per cent, of abortions in cases of pregnancy 
associated with carcinoma of the fundus uteri. 

Dystocia. — As the carcinoma increases in extent there 
is formed a greater barrier to the delivery of the child. 
When the cervix is entirely surrounded by the growth it 
will usually not dilate and a cervical tear must occur if 
the child is delivered naturally. This may be associated 
with an extensive hemorrhage. A rupture of the uterus 
may occur partly as the result of strong uterine contrac- 
tions against the cervical obstruction which does not 
yield and partly as the result of the weakened condition 
of the uterus due to the malignant infiltration. 

Sepsis. — Sepsis is a frequent complication following a 
full-term delivery or abortion when associated with a 
carcinoma of the cervix uteri. The explanation naturally 
is the septic condition of the growth, which it is practically 
impossible to disinfect, and the traumatism of the cervix 
and fundus of the uterus. 

Symptoms. — Bleeding is the most constant symptom and 
corresponds in character to the bleeding of cancer of the 
cervix uteri when not complicated with pregnancy, but 
usually more profuse. 

Prognosis. — There is to be considered the prognosis 
of (1) the fetus, (2) of the mother in regard to the preg- 
aancy, and (3) the mother in regard to the carcinoma uteri. 



166 CARCINOMA OF THE UTERUS 

1. Fetus. — As has been stated, 30 per cent, to 40 per 
cent, of the cases if there is no interference have an 
abortion or miscarriage. Of the cases that go to term, 
some cases may be delivered normally with no more than 
the ordinary risks to the child. Usually if the child is 
delivered through the vagina there is an increased risk 
on account of the cervical obstruction. If the child is 
delivered by a Cesarean section it is practically with no 
increased risk. 

2. Mother as Influenced by the Pregnancy. — There is a 
greatly increased risk to the mother, if the delivery is 
through the vagina, from hemorrhage, sepsis, and rupture 
of the uterus. If the delivery is by Cesarean section, 
there is also some increase in the risk on account of sepsis. 
The complication of a carcinoma of the cervix uteri adds 
greatly to the risk of delivery. 

3. Mother as Influenced by the Carcinoma. — It is gen- 
erally considered that a carcinoma of the cervix uteri 
grows more rapidly as the result of the increased blood 
supply of the pregnancy. Formerly it was believed 
that a pregnancy interfered with the development of a 
carcinoma of the uterus, but this theory was probably 
erroneous. A carcinoma of the uterus prevents a preg- 
nancy, but a pregnancy probably does not interfere with 
the development of a carcinoma. 

In regard to the prognosis of the operation for the 
removal of a carcinoma of the cervix uteri when associated 
with pregnancy, there are two factors which influence it. 
In general, a hysterectomy during pregnancy is more 
easy than the removal of a non-pregnant uterus. The 
uterine ligaments are more relaxed, the uterus comes more 
easily into the abdominal wound, and is therefore more 
readily accessible. On the other side is the increased 
blood supply, and the greater tendency to hemorrhage 
associated with it. In general, however, the risk of remov- 
ing a carcinoma of the cervix uteri is increased if it is 
complicated by a pregnancy. 



CARCINOMA UTERI AND PREGNANCY 167 

Treatment. — The conditions which have to be considered 
in determining the treatment of carcinoma of the cervix 
uteri associated with pregnancy are the operability of 
the carcinoma and the viability of the child. For greater 
clearness of description the treatment will be considered 
under the following four headings: 

1. Carcinoma operable, child not viable. 

2. Carcinoma operable, child viable. 

3. Carcinoma inoperable, child not viable. 

4. Carcinoma inoperable, child viable. 

1. Carcinoma Operable, Child not Viable. — Under these 
conditions the indications are to remove the uterus without 
special delay by the abdominal route. If the pregnancy 
has passed the sixth month the operation will be easier 
if the size of the uterus is diminished by removing the 
fetus and placenta before doing the hysterectomy. Under 
the sixth month the uterus can be removed together with 
its contents. A simple and not a radical abdominal 
hysterectomy should be performed. The decision in 
regard to a case with a child not viable but close to that 
condition may have to be decided by the wishes of the 
patient. "With a disease progressing it would be unwise 
to delay unless the patient so elected. In general the 
child should be sacrificed in the interest of the mother. 

2. Carcinoma Operable, Child Viable. — Under these con- 
ditions the indications are to do a Cesarean section and 
then to proceed at once to do a simple abdominal hyster- 
ectomy. 

3. Carcinoma Inoperable, Child Viable. — In the interest 
of the mother the indication is to terminate the pregnancy; 
in the interest of the child it is to wait until it is viable. 

In the early months the chances of the child living to 
term are so small and the detriment of the pregnancy to 
the mother is so great that the indications would be 
to terminate the pregnancy. This can usually be done 
most advantageously through the vagina after the growth 
has been disinfected as thoroughly as possible with the 
curette and cautery. 



168 CARCINOMA OF THE UTERUS 

At a later period when the child is approaching viability 
the indication is to wait and to do a Cesarean section when 
the child is viable. This is safer both for the mother and 
the child than to deliver the child through the vagina. 
As the carcinoma is inoperable the additional disadvantage 
to the mother of the continuation of the pregnancy is 
more than balanced by obtaining a living child. 

4. Carcinoma Inoperable, Child Viable. — The indication 
is to do a Cesarean section. The danger to the mother in 
this operation is from sepsis, and in some cases it would 
probably be best to do a supravaginal hysterectomy to 
remove the part most likely to become infected. 



LITERATURE. 

Byrne. Trans. American Gynecological Society, vol. xvii, p. 42. 

Cullen. Cancer of the Uterus. 

Doderlein and Kronig. Operative Gynakologie. 

Knack. Zeit. f. Krebsforsch, vol. xi, p. 463. 

Percy. Surgery, Gynecology and Obstetrics, vol. xix, p. 452. 



CHAPTER VII. 

CARCINOMA OF THE ORAL OR BUCCAL 
CAVITY. 

Under this heading are grouped the carcinomata of 
the following organs or localities: 

Carcinoma of the tongue. 

Carcinoma of the cheek. 

Carcinoma of the palate. 

Carcinoma of the gums. 

Sarcoma of the jaws. 

Carcinoma of the lips. 
This is convenient because these structures, though 
anatomically separate, are so close together that two or 
more of the structures may be involved by the same 
growth, and it may not be possible to tell in which organ 
or locality the lesion started, even at an early stage of 
its development. For example, an epithelioma may begin 
in the mucous membrane in the angle between the tongue 
and the floor of the mouth, or that between the gums and 
the cheek. Even in its earliest stage it might involve 
two structures. 

Etiology. — They also have certain etiological factors 
in common. Excessive smoking, syphilis, and broken 
teeth are exciting causes of cancer of the cheek as well 
as of the tongue. Leukoplakia is a factor predisposing 
to the development of an epithelioma in several places in 
the mouth. It is therefore best to consider all these 
localities together, and then each one, in some detail, 
separately. 

Frequency. — In the year 1912, in the registration area 
of the United States, there were recorded 1838 deaths, 



170 CARCINOMA OF THE ORAL CAVITY 

1465 males and 373 females, from cancer of the buccal 
cavity. At the same rate there would have been ap- 
proximately 3000 deaths from this cause in the entire 
country, which is approximately 4 per cent, of the deaths 
from malignant disease of all parts of the body. In reality 
the total number of cases was considerably higher than the 
figures given. A considerable number of cases occurring 
in this region were permanently cured and never appeared 
in mortality records. On account of early diagnosis and 
relatively simple operations a larger percentage of cases 
are permanently cured in this locality, especially of the 
lip, than in other parts of the body. These cured cases 
should be added to the number given in the mortality 
records to correctly indicate the number of cases that 
actual^ -occurred. 

Sex. — Carcinoma of the buccal cavity is much more 
common in males than in females. This is shown both 
by hospital and mortality records. Of 207 cases reported 
by Meller from the Second University Clinic in Vienna 
between 1894 and 1904 there were 194, or 94 per cent, 
males and 13, or 6 per cent, females. Of approximately 
1613 cases taken from the literature by Meller, 84 per 
cent, were in males and 16 per cent, in females. Of the 
1838 deaths in the United States registration area during 
1912, there were 1465, or 80 per cent, males, and 373, 
or 20 per cent, females. The greater frequency of the 
habit of smoking in men is one cause of the more common 
occurrence of cancer of the mouth in males. 

Age. — In Meller's and in Steiner's series, that is, in 
hospital cases, the number of patients in the different 
decades was as follows: 





Meller's. 


Steiner's. 




21 to 30 years 


1 


2 


1 per cent 


31 to 40 " 


. 14 


13 


8 


41 to 50 " 


. 46 


34 


24 


51 to 60 " 


. 74 


54 


38 


61 to 70 " 


. 58 


20 


23 


71 to 80 " 


. 13 


2 


4 


80 


1 







ETIOLOGY 171 

The cases in Steiner's series were only of the cheek, 
gums, and tongue. It will be noticed that carcinoma of the 
mouth is decidedly more common between the ages of 
fifty-one and sixty years. The youngest case was twenty- 
four years of age, and there were only three cases, that is 
less than 1 per cent, under thirty years. Singer found the 
average of onset of 250 cases of carcinoma of the oral 
cavity to be 56.2 years. 

The ages by decades of the 1838 cases reported in the 
registration area of the United States for the year 1912, 
that is of mortality not of hospital records, are given 
in the following table: 

Cases. Per cent. 

39 years 108 5 

40 to 49 " 180 10 

50 to 59 " 396 21 

60 to 69 " 552 28 

70 to 79 " 443 24 

80 to 89 " 168 9 

90 " 21 1 

In these mortality records there were 4 cases under one 
year of age and 23 cases under ten years of age. These 
cases in early years probably were mostly of sarcoma of 
the soft parts, or of the bones, or of developmental defects. 
It will be noticed in the table that the greatest frequency 
was between sixty and sixty-nine years, which was one 
decade later than in the hospital records of Meller and 
Steiner. The explanation of a part of this greater age of 
cases in the mortality statistics is that the hospital cases 
were seen earlier. The mortality records were of the ter- 
mination of the disease and would average two or three 
years later. 

Smoking. — There seems to be no doubt that tobacco 
smoking is the first in importance of the etiological 
causes of carcinoma of the oral cavity. There are a 
number of irritating factors in tobacco smoking that 
influence the development of cancer. They are the 
chemical irritation of the tobacco smoke and the tobacco 



172 CARCINOMA OF THE ORAL CAVITY 

juice, the physical irritation of the pipe, and the burning 
by the hot smoke or by the pipe-stem. 

.Tobacco smoking is probably the principal cause of 
the greater frequency of cancer of the buccal cavity in 
men than in women. Against this it is argued that 
carcinoma of the mouth is no more prevalent among the 
women of the East, with whom smoking is common, than 
among women of the West, with whom smoking is un- 
common. Also, that the disease is by no means uncommon 
among those who have never smoked at all. 

Clinical evidence, however, strongly supports the belief 
that carcinoma of the mouth is much more frequent in 
smokers than those who have not the habit. 

Theoretical ly, smoking must be considered a cause 
of cancer of the buccal cavity. There are innumerable 
examples of foreign bodies held in the same place and 
producing a constant irritation which, beyond any reason- 
able doubt, have been the cause of a carcinoma. A pipe, 
particularly if the mouth-piece is rough, which is con- 
stantly held in practically the same place on tissue as 
delicate as the lip, must by analogy be considered a cause 
of cancer of the lip and mouth unless the theory that a 
constant irritation causes the growth of a cancer is dis- 
carded. If the stem is short and becomes hot there is 
another cause of irritation. 

There is no doubt that excessive smoking causes dry- 
ness of the tongue and mouth which predisposes to the 
formation of cracks, fissures, and ulcers, which heal slowly. 
These unhealed lesions are as surely precancerous as any 
that exist, and must be so considered. That these lesions 
are caused by excessive smoking is clinically proved in 
many cases by the cure of the lesion as soon as the 
smoking is stopped. It must be accepted, therefore, 
that there is ample theoretical and clinical proof that 
smoking does predispose to the development of cancer 
of the mouth. 

A further influence of tobacco smoking in the develop- 
ment of cancer of the mouth is its relationship to leuko- 



ETIOLOGY 173 

plakia bucallis. This will be considered later under 
leukoplakia. 

Syphilis. — The mouth is a frequent location for syphilitic 
lesions, and beyond doubt they predispose to the formation 
of cancer. Syphilis, smoking, and broken teeth are the 
three most frequent etiological factors of carcinoma of the 
oral cavity. 

Singer studied 93 cases of oral carcinoma in relation 
to syphilis and found that there were certainly 35 cases, 
or 37 per cent, and possibly 50 cases, or 53 per cent., that 
gave a history of syphilis. To compare these figures, 
he studied 436 cases of cancer, all in other parts of the 
body, and found certainly 15 cases, or 3.5 per cent., 
and at most 23 cases, or 5 per cent., with a history of 
syphilis. That is, there was a history of syphilis in at 
least 35 per cent, of the cases of oral carcinomata, com- 
pared with 5 per cent, at most of other carcinomata. 
These figures are strong evidence that syphilis is an im- 
portant element in the causation of cancer of the 
mouth. 

Syphilitic lesions are common in different parts of the 
mouth, on the tongue, the palate, the gums, the lips; 
no part is exempt. Scars and possibly chronic ulcers 
are the natural results of such lesions, and it is easy to 
accept theoretically that these conditions predispose 
to the development of cancer, and the studies of Singer 
are strong clinical evidence of such predisposition. 

The close relationship between syphilis and cancer 
of the mouth has, however, been questioned, and the 
more exact diagnosis of syphilis that is possible by modern 
laboratory methods will determine the correctness of 
present ideas. 

Chronic Irritation. — This is one of the three important 
factors in the production of cancer of the mouth. The 
organs and structures hen — the tongue, the cheeks, the 
lips, the palate all are more or less constantly moving, 
and any irregular or jagged fixed surface with which they 
come in contact is sure to irritate. 



174 CARCINOMA OF THE ORAL CAVITY 

The most frequent cause of the irritation is broken or 
decayed teeth acting on the tongue or cheek. The 
irritation from broken or badly fitting dental plates is 
another example of such irritation. Another is the 
irritation of smoking. This may be from the pipe, from 
burning, and from the smoke itself, and has been con- 
sidered under smoking. Still another is holding foreign 
bodies in the mouth. An example of this has been seen 
in workmen holding nails in the mouth. The East Indian 
habit of holding the betel nut in the cheek has been the 
cause of cancer of the mouth. The irritation in these 
cases is partly physical, but probably largely chemical 
from the juices extracted in the chewing. 

Leukoplakia Biiccalis. — This disease is known by a 
number, of different names, such as leukokeratosis, 
leukoma, smoker's patch, and chronic superficial glossitis; 
and probably there are a number of different but closely 
allied conditions grouped under the one name. The 
condition is not common; it is seen almost exclusively 
in the male sex, and rarely occurs before twenty years 
and usually after thirty-five years of age. Syphilis, 
alcohol, and smoking are supposed to be the etiological 
causes of leukoplakia. There is an hypertrophy or thick- 
ening of the epithelium, usually of the tongue or cheek, 
forming a patch of a gray color. The color is not unlike 
that caused by the application of a stick of nitrate of 
silver to mucous membrane, and it has the form of a 
warty excrescence rather than that of an ulceration. There 
is usually some inflammatory reaction around and beneath 
the patch. The superficial epithelium may be scraped off, 
leaving a red surface, which tends to bleed. 

Leukoplakia usually occurs on the dorsum of the 
tongue, but may also occur on the cheeks, lips, palate, 
vulva, and penis. Usually in the early stages there are 
one or more patches, each about 0.5 cm. in diameter. 
It spreads by the periphery, and later may involve a 
considerable part of the tongue. It follows a chronic 
course, resisting treatment, and may remain quiescent 



ETIOLOGY 175 

for years. During this time it is not painful, and gives 
the patient little or no discomfort. 

Leukoplakia is of interest here, as it predisposes to the 
formation of an epithelioma. This is true, not only of the 
buccal cavity, but of other parts of the body. A number 
of cases of epithelioma of the penis and the vulva have 
been preceded by leukoplakia. An important percentage 
of the cases of epithelioma of the tongue develop from 
leukoplakia. This does not mean that leukoplakia is a 
cancer, or that it necessarily ever becomes one; in fact 
we do not know the percentage of cases of leukoplakia 
that develop into carcinoma. 

It does mean that leukoplakia is a lesion that frequently 
precedes the development of epithelioma, and the knowl- 
edge of this fact should require that every case of leuko- 
plakia should be carefully watched for the first sign of a 
malignant change in it. 

Gout. — The cancer age corresponds to that of gout, 
but it is not usually considered that gout predisposes to 
cancer. 

Singer in his study of the etiology of oral cancer found 
an exception to this rule. In 93 cases of oral cancer, 
excluding all doubtful cases, there were 21, making 
23 per cent., in which a history of gout was apparently 
clear. In 436 cases of cancer from other parts of the 
body, including doubtful cases, there were only 15, making 
4 per cent., in which there was a clear history of gout. 

Alcohol. — It is not easy to determine the influence of 
alcohol in the production of oral cancer. It is usually 
considered one of the etiological factors, and statistics 
would seem to indicate the correctness of this view. It 
is, however, not easy to separate the influence of smoking 
from that of alcohol, as probably only a small percentage 
of those who drink to an excess do not also smoke. So 
far, however, as alcohol, either by direct irritation or by 
causing gastro-intestinal disurbances, causes ulcerations or 
other pathological conditions in the mouth, or interferes 
with th«' healing of such lesions, it is an undoubted in- 
fluence in the development of oral cancer. 



176 CARCINOMA OF THE ORAL CAVITY 



CARCINOMA OF THE TONGUE. 

Etiology. — Frequency. — Hertzler states that 5 to 7 per 
cent, of all malignant epithelial growths occur in the 
tongue. This is probably true if limited to the male 
cancer cases. In Bashford's mortality statistics, 5.4 per 
cent, of the males, 0.5 per cent, of the females, and 2.5 
per cent, of the total cancer deaths were from malignant 
growths of the tongue. 

Sex. — Carcinoma of the tongue is far more frequent 
in males than in females. Erlich, studying the cases 
in the clinic and private practice of von Eiselsberg, in 
Vienna, for the years 1901-1906, found only one woman 
in a series of 64 cases, or 1.6 per cent. Steiner found in a 
series of 51 cases from the University Clinic of Budapest, 
in 1909, only 2 cases, or 4 per cent., in females. Ryall 
reported 12.5 per cent, of cases in women. In Bashford's 
mortality statistics there were about seven times as many 
males as females that died of cancer of the tongue. The 
proportion of the two sexes must vary in a small series 
of cases, but probably the figures of Ryall are too high 
and those of Steiner a more correct average. The greater 
frequency of its occurrence in males is probably due to 
the greater prevalence of smoking and drinking. 

Age. — The earliest age at which carcinoma of the 
tongue occurred in Steiner's series was twenty-five years. 
He quotes one case which occurred at the age of seventeen 
years. Sixty per cent, of the cases were between the ages 
of forty-six and sixty years. 

In Bashford's statistics there were one male and two 
females, under twenty-five years of age in a total of 2086 
deaths from cancer of the tongue. 

Of Erlich's series, 15 cases occurred between the ages 
of forty and fifty years, 17 cases between fifty and sixty 
years, and 29 cases between sixty and seventy years. 
This period of occurrence of carcinoma of the tongue is 
not only that of the greatest frequency of carcinoma in 



CARCINOMA OF THE TONGUE 177 

general, but also the age of excessive tobacco smoking and 
that of greatest irritation from broken and jagged teeth. 

Syphilis. — The three most important factors in the 
development of cancer of the tongue are syphilis, excessive 
smoking, and diseased or sharp teeth. In cancer of no 
other organ, is the relation of cause and effect so definite 
as between these three etiological factors and the develop- 
ment of cancer of the tongue. By all reported a history 
of syphilis in 88 per cent, of his cases. Porrier, as quoted 
by Steiner, found a history of syphilis in 27 of a series of 
32 cases. In Steiner's series only 4 per cent, gave such a 
history. This is a very low rate, and is an incident of a 
small series. With the more exact diagnosis of syphilis 
and the discovery of many more cases than were supposed 
to exist the percentage may be even higher than those 
given above. 

The cancer may develop in a scar or an old syphilitic 
ulceration. The interval between the formation of the 
scar or the ulceration and the development of the malig- 
nant growth is subject to considerable variation. Steiner 
reports one case which developed eighteen months after 
the healing of a syphilitic lesion. 

Chronic Irritation. — -This is an important causative 
factor in the production of cancer of the tongue, and many 
examples due to mechanical, chemical and thermic irrita- 
tions are common in the literature. A frequent form of 
mechanical irritation, one of the three most common 
etiological factors of cancer of the tongue, is that from a 
broken or jagged tooth. Erlich found broken or carious 
teeth present in only 10 per cent, of the cases in his series, 
and is doubtful of the importance of traumatism as a 
causative factor in the development of carcinoma of the 
tongue. Most observers, however, believe that it is an 
important factor. DaCosta has seen a case of carcinoma 
of the tongue of a workman, apparently the result of con- 
stantly holding nails in the mouth. Numerous oases 
have been reported in which the exciting cause seemed 
to be ;i broken dental plate. An example 1 of thermal 

12 



178 CARCINOMA OF THE ORAL CAVITY 

irritation of the tongue is the hot smoke from a short 
pipe. In such a case there would be the additional 
irritation of the tobacco and of the pipe itself. The most 
common chemical irritant is tobacco smoking. AH writers 
place excessive smoking with syphilis and broken teeth 
as the three important factors in the causation of cancer 
of the tongue. The smoking produces a chronic inflamma- 
tion of the tongue, and the formation of small fissures or 
ulcers. Chemical irritants in the form of caustics used 
in the treatment of benign ulcerations have been reported 
as changing a non-malignant to a malignant growth. 
While one can readily accept that repeated application 
of a caustic could change a benign ulceration of the tongue 
into a malignant growth, the suspicion of such a case 
would be that it was an unrecognized malignant condition 
from the start. The practical lesson is that any ulcera- 
tion of the tongue that does not quickly respond to treat- 
ment should be considered as malignant unless it is proved 
otherwise. 

Pathology. — Practically all carcinomata of the tongue 
are squamous-celled or epitheliomata. When other varie- 
ties occur, they result usually from the extension of a 
growth which was primary in the neighboring salivary 
glands. 

Anatomically there are three types of epithelioma 
of the tongue, though all are closely related. The most 
frequent is (1) an ulceration practically from the start; 
less frequently at first, there is (2) a deey nodule on the 
tongue which later ulcerates; finally there is (3) a diffuse 
infiltration. 

1. The epithelioma may develop in a preexisting 
fissure, chronic ulcer, warty growth, or patch of leuko- 
plakia. It may be malignant from the start, and no 
abnormality may have been noticed either by the patient 
or the physician until an ulcer has formed. 

2. Less frequently a nodule can be felt in the tongue, 
which afterward breaks down, forming an ulcer. This 
type sometimes appears more malignant than the ulcera- 



CARCINOMA OF THE TONGUE 179 

tive. The explanation of this is probably that it is not 
so easily recognized, and therefore comes under observa- 
tion at a more advanced stage. 

3. In still other cases there is a diffuse infiltration 
involving a considerable portion of the tongue from the 
start. When the growth is located on the margin of the 
tongue it may have the appearance of a pedunculated 
growth. In other cases the ulceration is more flat and 
may cover most of the dorsum of the tongue. 

A number of cases have been reported of two epithelio- 
mata developing at the same time, but independently 
in different parts of the tongue. 

Site of Growth. — Carcinoma occurs most frequently 
on the margin of the tongue. It may occur on the tip, 
the dorsum, or on the under surface. If on the under 
surface, it spreads quickly to the floor of the mouth. It 
occurs more frequently on the anterior part of the tongue 
than on its base. 

Metastases. — It was formerly believed that the lym- 
phatic glands were involved late in the epitheliomata of 
the tongue, and that the enlarged glands associated 
with such a lesion were not malignant, but frequently 
were a result of absorption from the septic ulcerated sur- 
face. This belief was theoretically but not practically 
correct. An epithelioma usually runs a slow course, 
forming metastases late. An ulcerated lesion, such as an 
epithelioma of the tongue, would cause an inflammatory 
reaction and enlargement of the lymphatic glands. It is 
now known that metastases occur early in this location. 
This is explained in part by the abundant lymphatic 
supply of the tongue and in part by the frequent movement 
of the tongue which mechanically forces the cancer cells 
into the tissues. 

The lymphatic glands first involved depend on the 
location of the growth. If it is on the side or margin of 
the tongue the submaxillary glands are first involved 
and later the deep cervical glands. If the tip of the 
tongue is the seat, of the growth, the submental glands are 



180 CARCINOMA OF THE ORAL CAVITY 

the first involved. If the growth is at the base of the 
tongue, the deep cervical glands are first involved. It 
must be remembered that the lymphatic supply in this 
region is so abundant and intimate that any of the glands 
mentioned may be involved with a growth in any part 
of the tongue; also, that the glands on the side opposite 
to that on which the growth is located may be involved 
as well as those on the same side. Erlich found in his 
series that when the growth was distinctly limited to 
the margin of the tongue on one side, usually only the 
glands on that side were involved. This is an important 
point in the operative treatment of the disease. Metas- 
tatic deposits occur in the liver more frequently than in 
any other distant organ. The sublingual gland may be 
involved- by direct extension from the primary growth 
and the submaxillary gland by extension from the lym- 
phatic glands. Metastases away from the neck are rare. 

Symptoms. — Pain. — This is the only subjective symp- 
tom that is at all marked in the early stage of the disease. 
It is frequently severe, neuralgic in type, and often referred 
to the ear of the corresponding side. This is particularly 
the case when the growth is toward the base of the tongue, 
less frequently the case if near the tip of the tongue. The 
pain and soreness are increased by highly seasoned and 
acid foods, and by mechanical irritation, as from the teeth. 
When the growth extends to the floor of the mouth the 
movements of the tongue are greatly limited. This 
increases the pain and interferes more and more with 
talking, chewing, swallowing, and the control of saliva. 
If the growth extends to the alveolar processes the move- 
ments of the jaws are also limited. 

Salivation. — In some cases, particularly if the growth is 
large and in the late stages, salivation is present and adds 
to the discomfort of the patient. 

Diagnosis. — The conditions most frequently confused 
with carcinoma of the tongue are syphilitic gumma, 
primary syphilitic lesions, and tuberculosis. 

Gumma occurs most frequently on the dorsum and 



CARCINOMA OF THE TONGUE 181 

toward the base of the tongue. It is rarely on the under 
surface and toward the floor of the mouth. There is 
in both conditions a tendency toward ulceration. A 
negative Wassermann reaction is of more diagnostic 
value than a positive one, because in the latter case the 
two diseases may exist together. If the lesion is a gumma 
it should yield promptly to antisyphilitic treatment, or 
more positive means should be employed to definitely 
establish the diagnosis. 

A tuberculous ulceration has different characteristics 
than an epithelioma. The edges are less hard, and it is 
more frequently surrounded by a diffuse inflammation. 
Previous to ulceration the differential diagnosis is difficult 
and may be clinically impossible. In such cases it would 
be necessary to remove a piece for examination. 

If any ulceration of the tongue is not cured, or does not 
show definite improvement after a short period of treat- 
ment, a piece should be removed for microscopic examina- 
tion. Unless necessary, however, it is a mistake to cut 
into a malignant growth even to remove a piece for 
examination, on account of increased danger of meta- 
stases. 

The increased danger of metastases, however, is less 
than that of delay. If the lesion is not malignant no 
harm results from the removal of a piece for examination. 
If it is malignant, as may be determined by a frozen 
section, immediate operation can be performed. 

Course. — The disease runs a rapid course, and usually 
terminates if untreated within eighteen months. In 
the inoperable stage, on account of the limitation of the 
movements of the tongue, and in some cases also of the 
jaws, it is difficult for the patient to take the proper 
amount of nourishment. This leads to rapid emaciation 
and hastens the termination of the disease. For the same 
re; tsoiis the saliva mixed with the discharges from the 
growth are taken into the lungs and a septic pneumonia 
may result. By extension of the growth, or injury to it 
by movement of the tongue, a severe hemorrhage may 



182 CARCINOMA OF THE ORAL CAVITY 

result. This hemorrhage may be difficult to control on 
account of the growth, and may terminate fatally. 

Inanition, pneumonia, and hemorrhage are the most 
frequent causes of death. 

Treatment. — The removal of the growth gives the only 
chance of cure. This means the partial or complete 
removal of the tongue together with the submental and 
submaxillary and jugular chain of lymphatic glands on 
both sides of the neck. If the growth is not large, and 
can be widely removed, and still a part of the tongue 
saved, it is best not to remove the entire tongue. The 
partial removal is a less serious operation, the part of the 
tongue left is of functional value, and recurrences are not 
apt to occur in the remaining portion of the tongue but in 
the lymphatic glands. 

The removal of the tongue may be done through the 
mouth with or without an incision through the cheek, or 
it may be done through the floor of the mouth, or it may 
be done by splitting the lower jaw. 

The operation for the removal of the tongue is a severe 
one, and it is associated with a high mortality. In the 
series of 25 operative cases reported by Steiner, there were 
9 deaths, a mortality rate of 36 per cent. This rate is 
probably higher than the average. Of the 9 deaths there 
were 4 from pneumonia and 1 each from sepsis, erysipelas, 
hemorrhage, myocarditis, and collapse. Of Erlich's 
series of 51 cases, 13 died of the operation and 5 cases 
were free of recurrence at the end of three years. 

End Results. — These are unsatisfactory. Of the 16 
cases in Steiner's series that recovered from the operation, 
9 cases died within the first year, 4 cases in the second 
year, and the result of 3 cases was unknown. Of the 25 
cases in Steiner's series, 12 cases, or nearly 50 per cent., 
were operated upon within the first three months of the 
apparent onset of the disease. These figures are given 
to show the unsatisfactory end results of the operation for 
epithelioma of the tongue. It should not be understood 
that no cases are permanently cured. If the case is seen 



CARCINOMA OF THE CHEEK 183 

early and subjected to a radical operation, including the 
removal of the lymphatic glands, there is a fair chance of a 
permanent cure. The chance, however, is less than for 
epithelioma in most other locations. 



CARCINOMA OF THE CHEEK. 

Etiology. — Frequency. — Steiner reported 61 cases of 
cancer of the cheek as occurring in Dollinger's clinic 
during a period of ten years. It was a slightly more 
frequent disease at that clinic than cancer of the tongue 
during the same period. There was a higher per- 
centage of cases at that clinic during the period than is 
usually recorded, as ordinarily cancer is more common in 
the tongue than in the cheek. 

Sex. — In Steiner's series of 61 cases there were 59 
men and 2 women; that is, 3.4 per cent, females. This 
infrequency of epithelioma of the cheek in females cor- 
responds closely to that of epithelioma of the tongue and 
other parts of the buccal cavity. 

Age. — The youngest case in Steiner's series was twenty- 
seven years and the oldest seventy-two years. Seventy- 
two per cent, were between the ages of thirty-six and 
fifty-five years; 40 per cent, between the ages of forty-six 
and fifty -five years. 

Chronic Irritation. — In Steiner's series, excessive smok- 
ing was a frequent etiological factor. One of the two 
women in the series was an excessive smoker. Kummel 
considers that cancer of the cheek is more frequently the 
result of the irritation of broken and decayed teeth than 
cancer of the tongue. Leukoplakia occurs on the cheek 
and its influence in the development of cancer has already 
been considered. 

Pathology.— The growth is usually an epithelioma. It 
tends to spread to the gums of both the upper and lower 
jaws, and ;ilso Id the superior and inferior maxillary bones. 
The growth, according to Kummel, is especially apt to 



184 CARCINOMA OF THE ORAL CAVITY 

start well back on the cheek opposite a molar or wisdom 
tooth and to extend to the anterior pillar of the fauces 
and from there to both the upper and lower jaws, limit- 
ing their movements. It rarely perforates the cheek. It 
starts as an ulcerated area and frequently opposite a 
broken tooth. In Steiner's cases it occurred in 46 cases 
in the left cheek and in 15 cases in the right cheek. 

The lymphatic glands which may be involved are first 
the submaxillary, the upper superficial cervical and those 
about the parotid gland. Later, the deep cervical glands 
are affected. Steiner mentioned one case in which the 
glands of the side opposite to the growth were involved. 
This, however, is not the usual rule. 

Symptoms. — In the early stages the subjective symptoms 
are not marked and the presence of the growth is the only 
sign of the disease. There may be pain, increased by 
irritation of the teeth and the movement of the cheek. 
Later, when the growth is more extensive, pain is more 
marked, and if both maxillae are involved the movement 
of the jaws is more and more limited. This leads to 
difficulty in taking nourishment, emaciation, and pulmo- 
nary disturbances. 

Diagnosis. — A gumma is rare in the cheek. A simple 
ulceration resulting from diseased teeth, particularly 
if associated with inflammatory induration, is more fre- 
quently confused with carcinoma of the cheek. Tuber- 
culous ulcerations and actinomycosis must also be kept 
in mind. 

Prognosis. — Kummel considers carcinoma of the cheek 
less malignant than that of most other parts of the mouth, 
and that it remains for a longer time a local process. 
This may be due to the less extensive lymphatic supply 
of the cheek compared with that of the tongue and floor 
of the mouth. 

Treatment. — The only treatment is the removal of the 
growth and the regional lymphatic glands. It may be 
necessary to remove a considerable part of the cheek 
so that a plastic operation will be necessary to close the 



CARCINOMA OF THE PALATE 185 

opening. It is also frequently necessary to remove a 
part of the upper or the lower jaw. 

End Results. — Of the 61 cases of Steiner's series 33 
were subjected to operation. Of these cases there were 
3 operative deaths, all of which were due to pulmonary 
complications. Fourteen cases died of recurrence within 
the first year, 4 other cases within four years, and one in 
the sixth year. Three cases were free of recurrence over 
three years. Of these 1 case was operated upon previous 
to four years and 2 cases previous to six years. 

CARCINOMA OF THE PALATE. 

Etiology. — Frequency. — Primary carcinoma in this region 
is relatively rare. There were only 7 cases, including 
those which involved the tonsils in Steiner's series during 
a period of ten years, which was about one-seventh the 
number of cases of carcinoma of the tongue. In Meller's 
series there were 15 cases, or 7 per cent, of the cases of 
carcinoma of the oral cavity during the recorded period 
of ten years. 

Sex. — All the cases in Steiner's series were in men. 
In Meller's series of 15 cases there were 14 men and 1 
woman. 

Age. — The youngest patient in Meller's series was 
thirty-four years of age. Of Meller's cases 33 per cent, 
were between the ages of fifty and sixty years, and 
33 per cent, between the ages of sixty and seventy 
years. 

Pathology. — Histologically, carcinoma of the hard or 
soft palate is usually of the flat-celled variety or epithe- 
lioma. Kiimmel also speaks of a carcinoma originating 
in the glands of the palate. Sarcoma occurs in the palate, 
but less frequently than in the tonsil. Epithelioma of 
the palate may involve by extension the tonsil, the base 
of the tongue, the upper jaw, and the antrum of Highmore. 

The lymphatic glands involved are usually the deep 
cervical glands along the internal jugular veins. 



186 CARCINOMA OF THE ORAL CAVITY 

Carcinoma of the hard palate frequently perforates 
and involves the antrum of Highmore, and it may be 
difficult to determine in which place the growth was 
primary. 

A number of cases have been reported in which the 
growth was limited to the uvula. 

Prognosis. — The disease is progressive and ultimately 
terminates the life of the patient. Kummel considers 
that carcinoma of the palate has a relatively small degree 
of malignancy, grows slowly, and forms metastases late. 
This may be due in part to the smaller lymphatic supply 
and, if on the hard palate, in part to the immobility of the 
structure. 

Treatment. — The removal of a carcinoma of the palate 
usually requires not only the removal of the growth but 
also a part of the upper jaw. 

End Results. — Of 10 cases that were subjected to opera- 
tion in Meller's series of 15 cases the end results were 
ascertained in 9 cases. Of the 9 cases, 2 cases died of the 
operation, 2 cases in the first year, and 2 cases in the 
second year of recurrence; 2 cases lived over two years. 



CARCINOMA OF THE GUMS. 

Etiology. — Frequency. — Steiner in a series from Dol- 
linger's clinic in Budapest during ten years, reported 13 
cases of carcinoma of the mucous membrane covering the 
alveolar processes. These were not cases in which the 
growth started in the bones. At the time of operation, 
7 of these 13 cases had extended to neighboring parts, 
that is, to the cheek, lips, or hard palate. It is possible 
that some of these cases started at other points in the 
mouth and extended to the gums. During that same 
period there were 51 cases of cancer of the tongue; that is, 
epithelioma of the gums occurred with about one-quarter 
the frequency of epithelioma of the tongue, and is relatively 
a rare locality for a malignant growth to develop. 



CARCINOMA OF THE LIPS 187 

Sex. — All of the 13 cases in Steiner's series were in men. 
The greater frequency in the male sex corresponds with 
the occurrence of carcinoma in other parts of the oral 
cavity. 

Age. — All of the 13 cases were between the ages of 
forty-one and sixty-six years. Nine cases, or 69 per cent., 
were between the ages of fifty-one and sixty years. 

Pathology.— The growth is practically always of the 
squamous-celled type. It is always seen as an ulceration 
and tends to spread on to the cheek, lip, or floor of the 
mouth. The location of the growth in Steiner's cases 
was on the gums of the lower jaw in 10 cases and of the 
upper jaw in 3 cases. If the growth is on the lower jaw, 
the submaxillary and submental lymphatic glands are 
first involved and later the deep cervical glands. If the 
growth is on the upper jaw the deep cervical glands are 
involved. 

Prognosis. — This is' unfavorable even with operation. 
This is partly because the cases are seen late when metas- 
tases have already formed in the lymphatic glands, and 
partly on account of the location of the growth, which 
makes it difficult to remove it widely. 

Treatment. — This consists of the removal of the growth 
with part or the whole of the jaw on the same side. The 
lymphatic glands should always be removed. 

End Results. — Of 8 cases operated upon three years 
previous to the time of Steiner's report, there was one 
operative death, 4 cases died of recurrence within the 
first year, nothing known of the outcome in 2 cases, and 
one case died of an intercurrent disease after seven 
years, which makes 12.5 per cent, of permanent cures 
on the five years basis. 

CARCINOMA OF THE LIPS. 

Etiology. — Frequency. — In Bashford's mortality statis- 
tics, malignant growths on the lips caused l.(> per cent. 
of the male and 0.7 per cent, of the total cancer deaths. 



188 CARCINOMA OF THE ORAL CAVITY 

Cancer of the lip constituted about one-third of the 
malignant growths of the entire face. Clinical statistics 
would give a smaller percentage of cases occurring on 
the lips than mortality statistics, as a larger percentage of 
cancers on the face than on the lips are cured. 

Sex. — Hallstrom reports from the literature 2937 cases, 
including carcinoma of the upper and of the lower lip, 
of which 2634, or 89.6 per cent., were in males and 303, 
or 10.4 per cent., were in females. Of 1683 cases of car- 
cinoma of the lower lip alone, also reported by Hallstrom, 
1543, or 91.7 per cent., were in males and 140 cases, or 

8.3 per cent., were in females, and of 95 cases of carcinoma 
of the upper lip, 56 cases, or 58.9 per cent., were in males 
and 39 cases, or 41.1 per cent., were in females. The 
proportion of males to females in carcinoma of the lip 
(including carcinoma of the upper and lower lip) is 8.6 
to 1, of the lower lip alone, 11 to 1, of the upper lip alone, 

1.4 to 1. These figures show that carcinoma of the lip, 
especially of the lower lip, is much more frequent in males 
than in females; but that carcinoma of the upper lip is 
only slightly more frequent in males than in females. 

Age. — The ages by decades of 120 cases of carcinoma 
of the lip, reported by Hallstrom are given in the following 
table : 

30 years 6 cases. 

30 to 40 " 5 " 

40 to 50 " 24 " 

50 to 60 " 41 " 

60 to 70 " 29 " 

70 to 80 " 10 " 

80 to 90 " 5 " 

Total 120 " 

The largest number of cases was between the ages of 
fifty and sixty years. Practically 80 per cent, of the cases 
were between the ages of forty and seventy years and only 
10 per cent, under the age of forty years. 

In a total of 2027 cases from mortality statistics, 
Bashford reported only 1 case, a female, under twenty-five 
years of age. 



CARCINOMA OF THE LIPS 189 

Chronic Irritation. — This is probably the most common 
cause of carcinoma of the lip. Smoking a pipe has long 
been considered a form of chronic irritation which causes 
carcinoma of the lip. It has, however, of late been 
doubted that it is as important a causative factor as was 
formerly believed. Theoretically a clay pipe with a short 
stem, which is both rough and hot, might well cause a 
chronic irritation of the lip which would be a factor in 
producing a malignant growth. The smoother pipe- 
stems in use at present would diminish the amount of 
irritation from this cause. 

Frequently a burn, crack, fissure, or ulcer of the lip is 
formed, and its healing is prevented by the movements 
of the lips or by constant irritation. This irritation may 
be from the teeth, from anything held in the mouth, or 
from exposure to the weather. As a result of the inter- 
ference with healing a lesion previously benign is changed 
to a malignant condition. There are examples of car- 
cinomata being caused in other parts of the body by 
repeated burns of a moderate degree, and there is little 
doubt that this frequently occurs on the lip. 

Constant exposure to weather is another form of chronic 
irritation frequently given as a cause of carcinoma of the 
lip. Carcinoma of the lip is more common in men, such 
as farm laborers, sailors, etc., who are constantly exposed 
to severe weather conditions, than in men who work 
indoors. On account of severe weather the lips become 
dry, easily cracked, and slow to heal. 

Pathology. — Carcinoma of the lip is practically always 
composed of flat epithelium, and is of the type of epithe- 
lioma. The primary or precancerous lesion may be a 
fissure, a vesicle, a hard nodule, a burn, or a simple ulcer, 
and is most often situated at the junction of the mucous 
membrane and the skin. The most frequent lesion first 
noticed by the patient is a small ulceration. The edges 
of this ulceration are elevated, and it is surrounded by an 
area of hard induration. The growth may extend and 
involve the whole lip, or to the mucous membrane of the 
mouth. 



190 CARCINOMA OF THE ORAL CAVITY 

Lymphatic Glands. — The submental lymphatic glands 
are the earliest and most frequent glands to be involved. 
The submaxillary glands are next in order and later the 
more distant glands of the neck. The sublingual gland 
may also be involved. The lymphatic glands of the 
opposite side as well as those of the same side as the growth 
may contain metastases. Enlarged glands are not 
necessarily metastases. They may be enlarged as a result 
of infection, but this can be determined only by micro- 
scopic examination of the excised glands. 

Location. — Of 1778 cases reported by Hallstrom, 
1683 cases, or 95 per cent., were in the lower lip and 95 
cases, or 5 per cent., were in the upper lip. 

The following table, adapted from combined statistics 
reported by Hallstrom, gives the frequency with which 
different parts of the lower lip are involved. 

Right angle 2.0 per cent. 

Left angle 2.5 " 

Middle 19.5 

Right half 26.0 

Left half 24.0 

Entire lip 26.0 

100.0 

It will be noticed that one-half of all cases are situated 
on one-half of the lip, and slightly more frequently on the 
right than on the left half. The actual number of these 
cases is larger than is indicated in the table, because the 
cases in which the entire lip was involved were advanced 
cases, and it was not possible to determine the location 
of the beginning of the disease. Dividing the cases which 
occupied the entire lip equally among the middle and the 
right and left halves of the lip, there would be 75 per cent., 
or three-quarters of the cases of carcinoma of the lower 
lip which started at one side of the middle of the lip. 
The number of cases of carcinoma of the upper lip in 
any series is so small that no figures can be given to show 
the relative frequency with which different parts of the 



CARCINOMA OF THE LIPS 191 

lip are involved, but probably they are the same as for 
the lower lip. 

Symptoms. — Earliest. — The symptoms of carcinoma of 
the lip are the objective signs of the growth itself, as 
there are no constitutional or general symptoms until the 
terminal stage. 

It is not strictly correct to speak of the symptoms of a 
disease before the disease exists, but the earliest symptoms 
of carcinoma of the lip should be considered to be the 
fissure, or burn, or ulcer, or vesicle, or nodule in which the 
carcinoma may develop. Not only should these lesions 
be looked upon as the earliest symptoms of carcinoma of 
the lip, but they should be treated as such. If they occur, 
every effort should be made to cure them promptly. 
If they are not quickly cured, they should be removed and 
subjected to microscopic examination to determine their 
exact nature. 

The later symptoms are those of a slowly advancing 
malignant ulceration. The surface bleeds easily. It has 
a thin discharge. The edges are elevated so that the 
growth, though ulcerated, has a definite tumor formation. 

Prognosis. — Carcinoma of the lip is of slow growth. 
Metastases are formed late, and then, as a rule, in the local 
lymphatic glands. The duration of the disease not 
infrequently is 3.5 to four years. 

Treatment. — Under this heading should first be con- 
sidered the treatment of the precancerous lesions, that is, 
the fissure, or burn, or nodule that may be the forerunner 
of a real cancer of the lip. Bloodgood has shown the 
importance of the immediate treatment of these conditions. 
The removal of them is a slight operation, it can be done 
under local anesthesia, and practically without risk, and 
they are all cured. These cases, however, must not be 
mixed or included in series of real cases of carcinoma of the 
lip. A precancerous lesion is a benign lesion, and therefore 
has no tendency to recur. By curing such a lesion, 
however, ;i true malignant condition may be prevented. 



192 CARCINOMA OF THE ORAL CAVITY 

The treatment of a carcinoma of the lip is its radical 
removal at the earliest possible moment, together with 
the lymphatic glands which drain the involved area. 
The removal of the primary growth, if it is at all extensive, 
may require the removal of all or a considerable portion 
of the lip. This requires a more or less extensive plastic 
operation to reconstruct a new lip. 

In the past, and to some extent at present, there is a 
tendency not to remove the lymphatic glands in the 
early cases, especially if they cannot be palpated, on the 
assumption that they are not involved. In many cases, 
it is true, that they are not involved, but there is no 
positive way to determine this except by microscopic 
examination of the removed glands. Operative results 
prove the wisdom of removing the lymphatic glands in 
all cases. If the case is early the removal of the barrier 
of glands, that is, the submental and submaxillary glands 
of both sides, will suffice. This can be done by an incision 
concealed beneath the inferior maxilla, with little or no 
deformity. In more extensive cases the cervical lymphatic 
glands must also be removed. The removal of the glands, 
if necessary with the superficial muscles, should be 
accomplished in a single mass. This may be an extensive 
operation, and in some cases the primary growth is 
removed at one operation and the cervical glands a few 
days later. This is not the best plan, and a two-stage 
operation should be avoided if possible. Statistics show 
a greater percentage of recurrence after two-stage than 
after one-stage operations. This is partly due to the 
more advanced state of the disease, which necessitated 
the two-stage operation. The removal of the cervical 
glands before the removal of the primary lesion has been 
advocated because the chance of scattering cancer cells 
into the system by handling the primary growth in remov- 
ing it will be avoided by having the lymphatics blocked. 

Following an operation the case should be carefully 
watched for any sign of recurrence, as frequently the 



CARCINOMA OF THE LIPS 193 

recurrence is entirely local and can be removed with 
permanent success. 

Operative Mortality. — This depends entirely on the 
extent of the case. In the early stage the removal of the 
primary growth with the neighboring lymphatic glands is 
associated with practically no mortality due to the opera- 
tion itself. An advanced case, necessitating an extensive 
neck dissection, is associated with a greater risk. In a 
series of 113 cases during a period of ten years reported 
by Hallstrom there was one death, or 0.9 per cent., 
mortality. 

End Results. — These depend largely on two factors: 
the extent of the disease at the time of the operation and 
the extent and nature of the operation itself. Even with 
an early lesion, an operation not sufficiently radical or 
without proper attention to lymphatic glands does not 
give favorable end results. The same is true of any 
operation, if the lesion is an extensive one at the time 
of surgical interference. Hertzler states that the percent- 
age of permanent cures of carcinoma of the lip "is not 
much over 25 per cent." It is not possible to state whether 
this estimate is correct or not. It is possible or even prob- 
able, if all different operations, by all operators, and all 
cases are included (and of course this is the only correct 
way in which to get the true percentage of permanent 
cures), that the percentage of 25 per cent, is approximately 
correct. It does not, however, do justice to the work of 
the best institutions. In a series of 80 cases reported by 
Hallstrom, 67.75 per cent, were well and without recurrence 
at the end of three years. This is probably a fair per- 
centage of permanent cures in any series which includes 
all types of cases, and is large enough to furnish fair 
averages, and in which the radical removal of the primary 
growth is associated with the extirpation of the lymphatic 
glands. In a series which included only early cases, the 
percentage of permanent cures would probably be as high 
as 90 per cent. 

13 



194 CARCINOMA OF THE ORAL CAVITY 



CARCINOMA OF THE FACE. 

Etiology . — Frequency.— In the United States registration 
area in 1912 there were 1743 deaths from cancer of the 
skin. In the same proportion there would have been 
in the entire country 2750 deaths from that cause. This 
was about 4 per cent, of the cancer deaths for the year. 
The greater part, but not all, of these cases doubtless 
occurred on the face, because carcinoma of the skin is 
relatively uncommon elsewhere. These figures, however, 
do not correctly represent the frequency with which 
carcinoma occurs on the skin, as many cases of carcinoma 
of the face are cured, or have such a mild degree of malig- 
nancy, that it is not the direct or recorded cause of death. 

Hertzler, quoting Heiman, states that 10 per cent, 
of all carcinomata occur on the face. 

In Bashford's mortality statistics, malignant growths 
of the skin of the face, lip, nose, scalp, and ear constituted 
2.4 per cent, of the total deaths from cancer. There were 
about twice as many males as females. 

Age. — The following table gives by decades the ages 
of 181 cases of carcinoma of the face reported by Maras- 
sovich, and shows the ages at which the condition is 
most frequent : 

24 to 30 years 3 cases. 

31 to 40 " 7 

41 to 50 " 30 

51 to 60 " 50 

61 to 70 " 56 

71 to 80 " 30 

80 " 5 

181 



It will be noticed that the largest number occurred 
between the ages of sixty-one and seventy years. 

Of the 1743 deaths from cancer of the skin reported 
in the United States registration area for 1912, the largest 
number, 28 per cent., occurred between the ages of seventy 



CARCINOMA OF THE FACE 195 

and seventy-nine years. There were 20 cases under ten 
years of age. 

Sex. — Of 182 cases reported by Marassovich, 102 cases, 
or 55 per cent., were in males and SO cases, or 45 per cent., 
were in females. Of the 1743 deaths from cancer of the 
skin reported in the United States registration area for 
1912 there were 61 per cent, males and 39 per cent, 
females. The greater exposure of men to the weather, 
injury, and irritation probably explains the greater 
frequency of carcinoma of the face in males than in females. 

In Bashford's statistics there were 1390 males and 637 
females recorded as having died of malignant growths of 
the skin of the face, lip, nose, scalp, and ear. If the 
growths on the lip were excluded there were 874, or 60 
per cent, males, and 588, or 40 per cent, females. 

Chronic Irritation. — The fact that the face and hands 
are more frequently the seat of carcinoma of the skin 
than other parts of the body is doubtless due in part to 
the greater exposure to weather conditions and to injury. 
It has been shown elsewhere that sailors, farm laborers, 
and others who are constantly exposed to extremes of 
weather conditions, the heat of summer, and the cold and 
possible freezing of winter, are especially disposed to 
cancer of the face and hands. 

For the 182 cases reported by Marassovich, 65 per cent, 
were country people and 25 per cent, more were classified 
as laborers. 

Pathology. — There are two types of carcinomata that 
are found on the face, (1) superficial and (2) deep. 

The superficial type is the basal-celled carcinoma of 
Krompecher and the rodent ulcer or cancroid of older 
writers, and is the least malignant of all carcinomata. 
It is usually located above a line extending from the 
labial fold to the ear. It is usually single, but many 
cases recorded are of multiple growths. The original 
lesion, that is, the precancerous lesion, may be a warty 
protuberance or a slightly elevated patch covered with 
scales. After a long period, frequently a number of 



196 CARCINOMA OF THE ORAL CAVITY 

years, such a lesion may become malignant. The growth 
even then is slow, and it may be difficult, even with a 
microscopic examination, to determine its malignant 
nature. Ultimately an ulceration forms which may 
become extensive and involve a large area of the face. 
Usually it remains small, the ulceration may be covered 
in whole or in part by modified epithelium and seem to 
be healed, though the growth is extending beneath this 
covering. 

The deep type is the usual epithelioma. It is most 
common on the lower lip, but also occurs elsewhere on 
the face. It is more malignant than the superficial type, 
but less so than most other forms of carcinomata. The 
earliest or precancerous lesion may be a small wart, or 
nodule, .or fissure. The ulceration is usually the first 
abnormality noticed by the patient, and has the usual 
characteristics of a malignant ulcer. It is hard and 
indurated, it has prominent edges, and is covered with a 
thin discharge. 

Lymphatic glands, in the superficial type, are usually 
not involved at all unless the ulceration becomes very 
extensive. In the deep type they are involved late in the 
disease. 

Location. — The following table gives the location in 
179 cases of carcinoma of the face reported by Maras- 
sovich, and illustrates the relative frequency with which 
different parts of the face are involved : 

Nose 50 cases 

Lower lip 47 

Upper lip 5 

Inner angle of eyelids 20 

Outer angle of eyelids 9 

Forehead 14 

Ear 4 

Cheek 22 

179 " 

Most frequently the growth starts at the junction of 
skin and mucous membrane. 



SARCOMA OF THE JAWS 197 

Symptoms. — They are the objective signs of the tumor, 
as described under pathology, and there are no subjective 
symptoms until an advanced stage. There is no pain 
or itching, and the condition is unfortunately often 
neglected by the patient. The two lesions most frequently 
confused with epithelioma of the face are syphilis and 
lupus. 

Treatment. — This is different for the superficial than 
for the deep type of carcinoma. 

The superficial variety has such a low degree of malig- 
nancy that an extensive removal is unnecessary. Many 
of these cases are cured by caustics, Roentgen rays, 
radium, or the cautery. If these agents are used the 
case requires careful watching, as sometimes the ulcer 
is healed superficially, but continues to extend beneath 
the epithelial covering. This has happened in some 
cases supposed to have been cured by the use of radium. 
Freezing with liquid air or carbonic acid snow has given 
excellent results. These agents are of particular value 
in treating carcinomata of the eyelids and the side of 
the nose, as they destroy the growth and leave less 
deformity than the removal of the growth by a cutting- 
operation. 

The treatment of the deep variety of carcinoma of 
the face is the same as that of carcinoma elsewhere. It 
is the wide removal of the primary growth with the 
extirpation of the neighboring lymphatic glands. The 
treatment of epithelioma of the lip is described elsewhere. 

SARCOMA OF THE JAWS. 

Etiology. — Frequency. — The jaws, both the upper and 
lower, are the bones most frequently affected by sarcomata. 
The upper and lower jaws are affected in about the same 
proportion. Ilertzler states that nine-tenths of the tumors 
of the jaws are sarcomata. 

Aye. — Sarcoma in general is more common in early 
years than carcinoma. Scudder gives the following 



198 CARCINOMA OF THE ORAL CAVITY 

percentages for age periods in a total of 148 cases from 
combined statistics for sarcoma of the upper, the lower, 
and both jaws: 

1 to 10 years 8.8 per oont. 

11 to 20 " 14.1 

21 to 30 " 19.5 

31 to 40 " 18.9 

41 to 50 " 11.5 

51 to 60 " 16.2 

61 to 70 " 8.8 

71 " 2.1 

99.9 

It will be noticed that 8.8 per cent, of the cases occurred 
between one and ten years of age, and that nearly three- 
quarters of the cases were under fifty years of age. Of 
26 cases reported by Scudder from the Massachusetts 
General Hospital, practically the same percentages for 
corresponding ages were given. There were 2 cases, or 
8.5 per cent, under ten years of age and 19 cases, or 80 
per cent, under fifty years of age. 

Sex. — The two sexes seem to be attacked with the same 
frequency by sarcoma of the jaw. Of 32 cases reported 
by Scudder, 19 cases were in males and 13 cases in females. 
In a total of 158 cases from combined statistics reported 
by Scudder, including his own cases, there were 74 males 
and 84 females. 

Trauma. — There is no doubt that a single injury to 
a bone is occasionally followed by a sarcoma. Sarcoma 
probably develops more frequently in the jaws following 
a trauma than in any other bone. Lowenstein records a 
number of cases of sarcoma of the upper and of the lower 
jaw which started within a few months of a single injury. 
He reports a case of sarcoma of the jaw which developed 
two months after the extraction of a tooth. 

Pathology. — Sarcoma of the jaw may arise from the 
periosteum forming a periosteal sarcoma or from the 
centre of the bone forming a medullary sarcoma. His- 
tologically the sarcoma may be of the giant-celled, round- 



SARCOMA OF THE JAWS 199 

celled, or spindle-celled variety. Melanosarcoma also 
occurs, though infrequently, in the jaw. Of these varieties, 
as a rule, the giant-celled is the least malignant, and the 
round-celled and melanosarcoma are the most malignant. 

In the upper jaw the bone is thin and a medullary sar- 
coma is rare, and the periosteal type is common. The 
most frequent site for a beginning sarcoma of the upper 
jaw is in the antrum of Highmore. In the earliest stages, 
when the growth is still limited to the antrum, there is 
no deformity to indicate its presence. Later, as the sar- 
coma grows, the bony wall of the antrum of Highmore 
may yield in any direction. In part the bone is absorbed 
and thinned, and in part new bone is formed over the 
tumor. In a still later stage, the growth may perforate 
through the bone into the soft parts. It may ulcerate 
through the cheek, though usually the skin of the face 
remains intact even at the termination of the disease. 
As a sarcoma of the upper jaw grows outward, there is an 
increasing swelling or fulness of the cheek. If it extends 
toward the orbital plate, the eyeball may become dis- 
placed. If it extends toward the nasal cavity, there is a 
gradual occlusion of the passage of the corresponding 
side. If it extends downward toward the palate process, 
there is first a bulging and later a perforation of the 
hard palate. The growth may extend backward and fill 
the posterior nares. 

After the antrum of Highmore, the alveolar process is 
the most frequent location of a sarcoma of the upper 
jaw. In some cases sarcoma of the upper jaw starts 
from the periosteum as a growth in the nasal cavity. 

In the lower jaw both the periosteal and medullary 
varieties of sarcomata are found. The medullary sarcoma 
is nearly always of the giant-celled type, and is of a 
relatively low grade of malignancy. Other varieties may 
occur. The medulla of the bone is progressively replaced 
by the growth of the sarcoma. As it develops, the bone 
is gradually absorbed and thinned, and at this stage 
crepitation may be detected by palpation. With the 



200 CARCINOMA OF THE ORAL CAVITY 

growth of the sarcoma and the thinning of the bone a 
swelling of the jaw develops. This is at first limited to the 
inferior maxilla, but later may involve the soft parts. 

A periosteal sarcoma of the inferior maxilla, which is 
more frequently of a round- or spindle-celled variety, 
grows around the bone but does not destroy it, as is done 
by a medullary sarcoma. The soft parts are involved 
at an earlier stage. The periosteal sarcoma is usually 
more malignant than the medullary variety. This greater 
malignancy of the periosteal sarcoma of the lower jaw 
is probably due to the greater frequency of the round- 
celled type, and to the earlier involvement of the soft 
parts by extension. 

Lymphatic Glands. — Metastases from a sarcoma of the 
upper jaw occur relatively late and recurrences are usually 
local and not in the lymphatic glands. A sarcoma in 
the lower jaw probably causes metastases at an earlier 
stage than a similar variety of the upper jaw. These 
statements, however, are general and not absolute. 

Metastases from a giant-celled sarcoma of the upper 
or of the lower jaw occur only after the disease has reached 
an advanced stage. It is claimed by some observers, 
that giant-celled sarcomata of the jaws do not form 
metastases at all. 

Symptoms of Sarcoma of the Upper Jaw. — The earliest 
symptoms of a sarcoma of the upper jaw — that is, the 
symptoms that exist before there is any swelling or de- 
formity — depend on the part of the bone in which the 
growth starts. 

If the growth starts in the antrum of Highmore the 
symptoms resemble those of an empyema of that cavity. 
There is over the antrum an indefinite pain or soreness, 
and there is a persistent foul discharge, possibly bloody, 
from the nose. Later there is swelling of the mucous 
membrane of the nose and soreness and pain in the teeth. 

If the growth starts in the alveolar process the earliest 
symptom is probably pain in the teeth. Later the teeth 
become loose and the gums swollen and edematous. 



SARCOMA OF THE JAWS 201 

If the growth starts in the nasal cavity the earliest 
symptoms are similar to those of a nasal polyp. There is 
an obstruction to the nasal passages on the side of the 
growth, and there is a foul, often bloody, discharge. 

At a later stage, if the growth starts in the antrum, 
the symptoms are somewhat increased in severity, but 
the pain is not excessive, and the symptoms are those 
due to the deformity and presence of the growth. The 
first change usually noticed is the fulness and swelling 
of the cheek. The pressure upward by displacing the 
eyeball may cause double vision. There may be some 
bulging toward the nose or the mouth. By examination 
the antrum will be found filled with a solid body. 

At this later stage, if the growth started in the alveolar 
process, in addition to the pain and soreness, some of the 
teeth will probably have been extracted and the growth 
will be seen in the resulting cavity. In some cases it may 
appear between two teeth as an epulis. 

In the latest stage of the disease it may be impossible 
to determine in which part of the superior maxilla the 
growth started. The swelling of the cheek is much more 
marked. The function of the eye and nose on the involved 
side may be entirely destroyed. The facial deformity 
that may be caused by an advanced sarcoma of the 
superior maxilla may be as distressing as any that occurs 
in surgery. 

Symptoms of Sarcoma of the Lower Jaw. — The earliest 
symptom may be an indefinite pain in the teeth, or the 
formation of a growth in the cavity remaining after the 
extraction of a diseased tooth, or the presence of the tumor. 

The later symptoms are those of the tumor. The 
medullary sarcoma produces a fusiform swelling that 
obviously involves only the bone. The outlines of the 
growth are definitely limited. The growth is usually 
neither painful nor tender. If the growth is periosteal, 
it is not so definitely limited to the bone itself. Although 
at first limited in its outlines, the growth extends to the 
soft parts earlier than the medullary type. 



202 CARCINOMA OF THE ORAL CAVITY 

In the latest stages it is not easy to determine the loca- 
tion of the origin of the sarcoma. The growth may be 
very extensive, producing marked deformity of the face. 
It may ulcerate through the skin, but usually does not. 

Prognosis. — The prognosis of sarcoma of the upper 
and of the lower jaw depends more on the type than on 
the location of the growth. The giant-celled sarcoma 
is usually the least malignant. It is of slow growth, 
and remains a long time as a local lesion, and it is per- 
manently cured by a simple operation. The most malig- 
nant are the melanosarcoma and the round-celled sarcoma. 
The periosteal sarcoma is usually more malignant than 
the medullary type. The prognosis of the more malig- 
nant varieties is less favorable, though a certain percentage 
of thentare cured. 

Treatment. — This depends on the histological type of 
sarcoma. If it is a giant-celled sarcoma a partial operation 
may be performed. That is, the growth can be exposed 
and scraped out without the removal of the entire bone. 
For a growth in the antrum of Highmore this would mean 
the turning back of a flap of the cheek and a portion of 
the superior maxillary bone. The growth may then be 
removed with a sharp spoon. 

Scudder believes that "any malignant growth, whether 
sarcoma or carcinoma, involving and filling the antrum, 
is best treated by excision of the entire upper jaw." The 
more extensive operation would cause a greater deformity, 
but would probably be safer. 

In the lower jaw the growth may be reached by the 
removal of one or more teeth or by the removal of an 
area of bone at the side of the inferior maxilla. The 
sarcoma is then removed with a sharp spoon. The cases 
of partial operation should be carefully watched for 
any sign of recurrence, and any recurrence should be at 
once removed. Some of these cases are operated upon 
many times for recurrences, and are ultimately perma- 
nently cured. There are also cases where a complete 
removal of the bone, either the superior or inferior maxilla, 



SARCOMA OF THE JAWS 203 

may be necessary on account of the extent of the disease. 
These cases, however, are usually round- or spindle-celled 
and not giant-celled sarcomata. 

For the round- or spindle-celled sarcoma the removal 
of the bone involved is usually indicated. In the superior 
maxilla this means the removal of the entire bone, includ- 
ing in some cases the orbital plate and the eye. In the 
inferior maxilla the half of the bone on the side involved 
may be removed. 

Unless apparently involved the cervical lymphatic 
glands are not removed if the growth is of the giant-celled 
type. They should be removed for round-, spindle- 
celled, and melanosarcoma. 

Operative Mortality. — This depends on the nature and 
extent of the growth and the general condition of the 
patient. It is not easy to give definite percentages of 
deaths from the removal of sarcoma of either the superior 
or inferior maxilla, because the series of cases from any 
one clinic is so small that a few unusual deaths greatly 
increase the mortality percentage. The removal of a 
sarcoma without the removal of the entire bone involved 
is associated with only a slight risk. The removal of 
the superior maxilla is associated with a greater mortality 
than the removal of the inferior maxilla. Scudder 
reported from the Massachusetts General Hospital 11 
cases of sarcoma of the superior maxilla, with one operative 
death, or a mortality of 9 per cent., and 15 cases of sarcoma 
of the lower jaw with no deaths. 

LITERATURE. 

Butlin. Diseases of Tongue. 
Da Costa. Keen's System of Surgery. 

Davis. Jour. Amer. Med. Assoc., lxii, No. 22, 1718; Deut. Zeit. f. 
Cliir., cxix, 142. 

Erlich. Arch. f. klin. Chir., vol. lxxxviii. 
Hiillstrom. Operations des Lippenkreben. 
Hertzler. Treatise on Tumors. 
Kummel. Krankheitcn des Mundes. 
Meller. Deut. Zeit. f. Chir., vol. lxxxiv. 
Ryall. British Med. Jour., April, 1913. 
Scudder. Tumor of the Jaws. 
Steiner. Deut. Zeit. f. Chir., vol. xcviii. 



CHAPTER VIII. 
CARCINOMA OF THE ESOPHAGUS. 

Etiology. — Frequency. — As more exact methods of diag- 
nosis are developed, there is an increased percentage 
of cases of carcinoma of the esophagus recorded. Early 
statistics gave its frequency as a fraction of 1 per cent, 
of all cases of carcinoma. In the Montreal General and 
Royal Victoria Hospitals, as reported by McCrae, in 265 
cases of carcinoma, there were 24, or 9 per cent., which 
were in the esophagus. This is a relatively small number, 
and there are no large series of clinical cases, as there are 
of some organs, such as the stomach, from which accurate 
percentages can be made. The percentages of cases found 
at the Montreal hospitals are approximately the same as 
reported recently from other institutions and probably 
correctly represents the frequency of carcinoma of the 
esophagus. The esophagus probably ranks next to the 
breast, uterus, gastro-intestinal tract and gall-bladder as 
the organ most frequently the site of a malignant growth. 

Sex. — There are more cases in males than in females. 
Of 772 cases, as reported by Kaus in Nothnagel's series, 
there were 584 cases in men and 188 cases in women, 
that is approximately 75 per cent, males and 25 per cent, 
females. In Bashford's mortality statistics, the ratio 
was three males to one female. 

Age. — In a total of 2832 cases of malignant growths 
of the esophagus, Bashford recorded only one male and 
one female under twenty-five years of age. Seventy 
per cent, were beyond fifty-five years of age. 

Cause. — Carcinoma of the esophagus seems to be more 
frequently found at the narrowest points in its lumen, 



PATHOLOGY 205 

and the greater irritation at these points is the possible 
cause. The irritation of tumors or strictures, which were 
originally benign, is a possible explanation of the develop- 
ment of some malignant growths. The same is true of 
esophageal pouches or diverticula. None of these causes 
are definitely proved, but they are the etiological factors 
which seem most probable and logical. 

Location. — Carcinoma of the esophagus occurs most 
frequently at the narrow anatomical points. The fact 
that carcinoma is most frequent at the narrowest places 
in the esophagus is generally considered as suggestive 
evidence that irritation is a causative factor in its produc- 
tion. Some writers have described as many as twelve 
normally narrow places in the esophagus, but this is a 
larger number than is ordinarily recognized, and more 
than is of practical value. The three most important 
anatomical points of narrowing, aud the three places at 
which carcinoma most frequently occurs, are opposite 
at the cricoid cartilage, at the bifurcation of the trachea, 
and at the cardiac orifice of the stomach. No part of the 
esophagus is exempt from carcinoma but probably carcin- 
oma is most frequent at the lowest of the three points 
or at least in the lowest third of the esophagus. 

Pathology. — Carcinoma is frequent as a primary lesion 
but occurs also as a secondary growth. The two varieties 
found are the squamous-celled and the adenocarcinoma. 
The squamous-celled is by far the most frequent type and 
originates in the lining epithelium. The adenocarcinoma 
is more rare and develops from the esophageal glands. 
At first the growth bulges toward the lumen of the esopha- 
gus, later it ulcerates and by cicatricial contraction forms 
a stricture. The obstruction in the esophagus may be due 
to the encroachment of the growth on its lumen, or to 
the stricture, or to the spasmodic stenosis produced by 
the presence of the growth. Above the stricture there 
may be a dilatation of the esophagus. The early symp- 
toms of carcinoma of the esophagus, as of other parts of 
the gastro-intestinal tract, are largely the result of the 



206 CARCINOMA OF THE ESOPHAGUS • 

obstruction to its lumen. Later the symptoms are due 
to the involvement of neighboring structures, and to the 
absorption of toxines of the growth itself. 

Metastases. — As a rule these are formed late. It has 
been stated that in 50 per cent, of the cases, no metastases 
are found even at autopsy. This high percentage of 
absence of metastases has been doubted. It may have 
been an estimate not based on exact scientific investiga- 
tion, or based on only a small series of cases, and may 
therefore not be accurate. There are, however, two 
factors that favor the correctness of the percentage, and 
explain the infrequency with which metastases are found. 
The common type of esophageal cancer is the squamous- 
or flat-celled variety, which ordinarily remains a local 
disease until a late stage, and does not form early metas- 
tases. Secondly, the malnutrition and emaciation result- 
ing from the difficulty or inability to take the proper 
amount of nourishment, cause the death of the patient 
before the disease has advanced to the stage at which 
metastases are usually formed. 

When the metastases do occur, and they are sometimes 
found in the early stage of the disease, even before marked 
symptoms are present, they are most frequently found 
in the neighboring lymphatic glands in the posterior 
mediastinum or in the liver. The cervical and supra- 
clavicular lymph glands, especially on the left side, may 
be involved later and can be palpated. 

Extension of the Growth. — The esophagus is surrounded 
by important structures, the involvement of which leads 
to definite symptoms or possibly to immediate death. 

Of the air passages, the growth may involve and per- 
forate into the larynx, trachea, bronchi or the lungs 
themselves. Perforation into the lungs would mean that 
there had been an involvement of the pleura with the 
formation of adhesions. Such a condition would lead 
shortly to pneumonia and death. The perforation of 
one of these structures is a frequent termination of an 
esophageal carcinoma. 



SYMPTOMS 207 

Of the vascular system, the growth may involve one of 
the larger arteries, or veins, or may rarely perforate the 
pericardium. The involvement of a larger artery or vein 
would cause a fatal hemorrhage. The involvement of a 
small artery or vein would lead more likely to its obstruc- 
tion. Perforation of the pericardium would cause death 
in a short time. 

Of the nervous system, most frequently there is pressure 
on the sympathetic and recurrent laryngeal nerves, pro- 
ducing paralysis of the parts supplied by them. Paralysis 
of the sympathetic or of the left laryngeal nerves strongly 
indicates the involvement of lymphatic glands. The right 
inferior larj'ngeal is more frequently involved with the 
primary growth. 

Symptoms. — Early. — Janeway, in an analysis of the 
first symptoms of twenty-one cases of carcinoma of the 
esophagus, found as follows: 

Dysphagia (permanent) 10 cases. 

Dysphagia (temporary) 3 

Dysphagia and pain 2 

Pain 2 

Tickling in throat 2 

Increased mucus in throat 1 

Loss of appetite 1 

21 



Dysphagia. — Janeway's table illustrates the frequency 
of dysphagia as a first symptom. It may at first be 
temporary and in attacks but usually it is permanent and 
progressive. There is at first difficulty in swallowing 
hard pieces of food, later of any solid food, then of liquids 
and finally it is impossible to take any or more than the 
smallest quantity of fluid. An attempt to swallow food 
brings on an attack of coughing with regurgitation of 
food. In some cases, especially if the malignant growth 
is low in the esophagus, and there is a dilatation above it, 
the regurgitation of food may be postponed some hours. 
Such food is distinguished from stomach contents by 



208 CARCINOMA OF THE ESOPHAGUS 

its alkalinity, and the absence of gastric juice and the 
products of gastric digestion. The regurgitated food may 
contain blood and rarely pieces of malignant tissue from 
the growth. 

Pain. — This is usually a late but may be an early 
symptom. In two of Janeway's cases it was the first 
symptom, that is, it preceded the d3'sphagia. The pain 
may be over the growth, or it may be confined to the back 
of the neck. It is usually increased by any attempt to 
take food. 

Pressure on Nerves. — If there is paralysis of both recur- 
rent laryngeal nerves there is paralysis of the vocal cords, 
loss of voice, and dyspnea. If only one recurrent laryngeal 
nerve is paralyzed the voice is changed but not entirely 
lost. 

If there is paralysis of the sympathetic nerve, there is 
contraction of the pupil on the affected side from paralysis 
of the dilator muscle, and narrowing of the lids or ptosis. 

Involvement of Air Passages. — This produces a cough 
with expectoration which is at first mucus but later 
becomes purulent. When the growth perforates the air 
passages, an aspiration pneumonia shortly occurs. 

Emaciation.— -On account of the difficulty or inability 
to take the proper amount of food, there is loss of flesh 
and strength more rapidly than with a growth of the same 
type elsewhere. The patient may be hungry but refrain 
from eating on account of the difficulty of swallowing. 

Diagnosis. — This is established only by the direct 
examination of the esophagus. This is done by the 
Roentgen rays, the olive bougie, and the esophagoscope. 
The symptoms given above, with the exception of the 
involvement of nerves and air passages, are largely the 
symptoms of a benign as well as of a malignant stricture, 
and further information is necessary to establish the 
diagnosis of carcinoma or a malignant stricture of the 
esophagus. 

The Roentgen rays by outlining the lumen of the esopha- 
gus will picture diverticula and diffuse dilatations of the 



DIAGNOSIS 209 

esophagus and give some information regarding external 
pressure on the esophagus. 

The use of bovgies is not without danger, and is not uni- 
versally recommended. The danger is in the perforation 
of the esophagus at the site of the growth which would 
be followed by a fatal local infection. In no case should 
an instrument be introduced into the esophagus without 
first excluding an aneurism. 

Plummer uses a silk thread as a guide for the bougie. 
A few inches from a spool of silk thread is coiled and 
swallowed by the patient, and during the same evening 
two or three additional yards are swallowed. The follow- 
ing morning, the same amount at the rate of a foot an hour 
is swallowed before the patient is again examined. The 
intention of this plan is to have the thread carried down 
into the intestine far enough so that it can be made taut 
without being withdrawn. On this thread as a guide^a 
bougie is threaded and passed to and through the stricture. 
By noting the point of obstruction, the location of the 
growth is determined. By the use of the bougies with 
tips of various sizes, the calibre of the stricture is 
determined. The bougie passed in this way is of value 
also in determining its rigidity. By using fenestrated tips, 
pieces of tissue for examination are sometimes brought 
away. 

The esophagoscope is not a new instrument, but it 
recently has been perfected, and brought into more 
frequent use. Its use is associated with considerable 
discomfort to the patient, often requiring an anesthetic, 
especially if the growth is in the lower part of the esopha- 
gus, and requires special skill of the physician. Through 
the esophagoscope, a direct view of the growth and a 
piece of tissue for examination is obtained. It is best not 
to use the esophagoscope directly after the use of the 
bougies, on account of the traumatism and possible 
slight bleeding caused by this examination. The bleeding 
even though slight may obscure the field, and it is better 
to wait for a more favorable opportunity. Neither 

14 



210 CARCINOMA OF THE ESOPHAGUS 

should the esophagoscope be used as a routine method of 
examination for all cases. If on account of subjective 
symptoms the case is obviously one of advanced carcin- 
oma, there is little to gain and considerable risk in the 
use of the esophagoscope, and it should therefore be 
avoided. In the early case, the use of the esophagoscope 
is the real method for a positive diagnosis. 

Treatment. — The removal of a carcinoma of the esopha- 
gus is, of course, the only treatment that offers any hope 
of a cure of the disease. The removal of a carcinoma of 
the cervical portion of the esophagus should be accom- 
plished without great risk, and with a definite chance of a 
permanent cure. Such cases are, however, very rare. 

The removal of a growth from the thoracic portion of 
the esophagus has not passed the experimental stage, 
though it has been done successfully. Meyer, Torek, 
and Janeway, in America, and Sauerbruch, in Europe, 
have done pioneer work in intrathoracic surgery and the 
time is probably not distant, when a carcinoma of the 
thoracic portion of the esophagus can be removed with a 
risk that is commensurate with the benefit to be gained. 
Such an operation has already been successfully performed. 
Torek, in Surgery, Gynecology, and Obstetrics, June, 1913, 
reports "The First Successful Case of Resection of the 
Thoracic Portion of the Esophagus for Carcinoma." 
This, however, does not remove the operation from the 
domain of experimental surgery though it justifies the 
work and furnishes a promise for the future. Torek 
brought the upper end of the divided esophagus out in 
the neck in front of the sternomastoid muscle. The 
lower end was inverted and a gastrostomy performed. 
Sauerbruch was not so successful in his work, and all 
of his cases, reported in available literature, died either 
directly or indirectly from the operation. 

Plummer, who has had remarkable success in the treat- 
ment of benign stricture of the esophagus by dilatation, 
recommends it also for malignant stenosis, as a palliative 
measure to relieve symptoms. By its repeated use, he 



TREATMENT 211 

has relieved dysphagia for a number of months. It 
should be done with care, as otherwise there is risk of 
perforation or rupture of the esophagus. If the dysphagia 
is too great a gastrostomy may be performed. It is not 
easy to decide in regard to a gastrostomy. If it is put 
off too late, either the patient dies from the operation, 
though it is a simple one, or from inanition due to inability 
to absorb nourishment that is taken. If it is done too 
early, the patient has an additional period of life under 
rather trying conditions. When the patient begins 
definitely to lose weight, it will probably add to his 
comfort. Greater comfort for the patient can sometimes 
be obtained by feeding through a tube. This may be 
passed for each feeding or a short tube may be passed 
through the stricture and left in place. In the latter 
case a string is attached to it and fastened to the teeth so 
that it can be withdrawn. 

For pain, the usual remedies are used. At first aspirin 
will give relief. Later codein or morphia hypoder- 
mically will be necessary. 



LITERATURE. 

Janeway. Amer. Jour. Med. Sci., cxlvii, p. 583. 

Kraus. Die Erkrankungen der Speiserohr (Nothnagel's System). 

McCrae. Osier's Modern Medicine. 

Meyer. Surgery, Gynecology and Obstetrics, xvii, 693. 

Plummer. Collected Papers, Mayo Clinic, 1911. 

Sauerbruch. Technik der Thorax Chirurgie. 

Torek. Surgery, Gynecology and Obstetrics, xvi, 614. 



CHAPTER IX. 
CANCER OF THE STOMACH. 

Etiology. — Frequency. — There are no statistics that 
give exactly the percentage of deaths from cancer of the 
stomach that occur in any locality or country. Hospital, 
autopsy, and mortality records are the three sources of 
information used to estimate the frequency of cancer 
of the stomach, but none of them is sufficiently accurate 
to give absolute information, and the records of different 
institutions vary greatly, but all taken together give 
sufficient information to form a general idea of the fre- 
quency of the disease. 

Lockwood reported that during a period of five years 
between 1904 and 1908 there were admitted to the medical 
divisions of Bellevue Hospital 84,564 cases, and of these 
143 were diagnosed as cancer of the stomach. That would 
be about one in 600 cases. Fen wick reports figures from 
six general hospitals in London, and all of these gave 
about one case of cancer of the stomach to each 200 
medical admissions. These are figures of cases that 
were diagnosed under favorable conditions but many of 
them at a time when the modern methods of diagnosis 
of gastro-intestinal diseases were not used, and undoubt- 
edly more cases of cancer of the stomach were overlooked 
than there were of other diseases not cancer of the stomach 
which were included as such. Probably the estimate of 
some writers, that 1 per cent, of medical admissions to 
general hospitals are for cancer of the stomach is more 
nearly correct. 

Autopsy statistics give even a higher percentage of 
cases of gastric cancer. In the combined statistics of a 



ETIOLOGY 213 

large number of autopsies, about 4 per cent, of the cases 
were of cancer of the stomach. The value of autopsy 
records is limited because autopsies are made on only a 
small proportion of all cases that die, and the cases are 
always somewhat selected. 

Mortality statistics are open to the objection that 
autopsy and pathological examinations are rarely made 
and diagnoses are frequently incorrect. 

Cancer of the stomach, however, is easy to diagnose 
when it has reached the last stages, and taken all 
together, mortality statistics probably give us the most 
correct information regarding the frequency of gastric 
cancer. 

The mortality statistics of the United States for 1912, 
as prepared by the census bureau, include cancer of the 
stomach and cancer of the liver under a single heading 
because they are so closely associated, and cancer of the 
liver is most frequently secondary to cancer of the stomach. 
During the year 1912, in the registration area, there were 
reported 18,517 deaths from cancer of the stomach and 
liver, which was about 40 per cent, of the deaths from 
cancer of all organs. In the entire United States, if the 
proportion of deaths from cancer was the same as in the 
registration area, there were about 29,500 deaths in 1912 
from cancer of these organs which is a death rate of 
30.8 per 100,000 population. These statistics must not 
be taken to indicate absolutely the frequency of death 
from cancer of the stomach. Cancer of the liver is rarely 
primary, but it is secondary not only to the cancer of the 
stomach but of other organs, in which primary malignant 
growths are entirely obscured by the secondary growths 
of the liver. 

They are, however, probably approximately correct. 
Mortality statistics of some foreign countries confirm 
them or give a higher death rate from gastric cancer. 

Hoffman has studied the mortality from cancer of the 
stomach and liver in the United States registration area 
for ten years from 1901 to 1910 limited to the population 



214 CANCER OF THE STOMACH 

over forty years of age, during which years about 90 per 
cent, of the cases of cancer of the stomach and liver occur, 
and gives the following table: 

MALES. 

Per cent, of all cancer Rate per 100,000 
deaths over forty over forty years 

Number. years of age. of age. 

Liver and stomach . 50,157 50.5 96.6 



FEMALES. 



Liver and stomach 



It will be noted that the actual number of deaths 
from gastric cancer was practically the same in both sexes. 
Also that this number constituted about one-half of all 
deaths from cancer in males over forty years of age, and 
about one-third of those in females. The large number of 
deaths of females from cancer of the breast and the 
generative organs, lowers the percentage of cancer deaths 
from other organs in that sex. 

The higher death rate of females per 100,000 popula- 
tion over forty years of age, is due to the difference in the 
number of the two sexes living at these ages. 

The number of deaths reported from cancer of the 
stomach is increasing each year. For example, the 
average annual number of deaths from cancer of the 
stomach and liver in the United States registration area 
from 1901 to 1905 was 8091, or 24.7 per 100,000 popula- 
tion, and from 1906 to 1910 was 13,395, or 28.3 per 
100,000 population, and in 1912 it was 18,517, or 30.8 
per 100,000 population. Beyond doubt a part of this 
increase is due to more correct diagnoses, but it is generally 
accepted that the actual number of cases of gastric cancer 
is on the increase. 

Sex. — Reference to the above table of Hoffman, will 
show that during the years 1901 to 1910 inclusive, there 
were about the same number of deaths from cancer of the 



ETIOLOGY 215 

stomach in each of the sexes. Of the 18,517 deaths 
from cancer of the stomach and liver reported in the 
United States registration area in 1912, 9215 were in 
males and 9302 in females. In Bashford's mortality 
statistics, in which cancer of the stomach is recorded by 
itself, there were 7149 males and 7119 females, who died 
of malignant growths of the stomach. 

Formerly it was believed that it was far more frequent 
in men that in women, but at present, because of more 
accurate statistics, it is generally accepted to be equally 
common in the two sexes. 

Age. — Cancer of the stomach is a disease of adult life. 
Approximately 90 per cent, of all cases are between the 
ages of forty and seventy years and only about 2 per cent, 
of the cases occur before the age of thirty years. The 
largest number is between the ages of fifty and sixty 
years. After seventy years there are comparatively few 
cases, largely probably because there are comparatively 
few people living after that age. Fenwick has shown that 
the number of deaths from carcinoma of the stomach in 
a given number of people, increases up to seventy-five 
years of age and that then there is a slight decrease. 

Heredity. — It is now generally accepted that heredity 
plays no part in the etiology of cancer, and this belief 
applies to cancer of the stomach as well as to other organs. 
Considering the frequency of cancer in general, the 
chances are that most people have a near relative who 
has died of cancer of some organ. It is probable that 
heredity has no other bearing on the presence of cancer 
of the stomach. 

Race. — Hoffman has prepared the following table 
from the mortality records of the District of Columbia 
for the ten years ending 1910, which gives by race as well 
as sex and age the periods of the death rates of cancer of 
the stomach and liver for the period: Rates per 100,000 
population. 



216 CANCER OF THE STOMACH 

MORTALITY FROM CANCER OF THE STOMACH AND 
LIVER. 

Males. Females. 

Ages. White. Colored. White. Colored. 



30 to 39 years 
40 to 49 " 
50 to 59 " 
60 to 69 " 

70 + 



9.7 15.2 8.7 11.3 

28.3 30.5 31.3 27.4 

89.5 84.4 87.6 91.0 

221.0 166.4 151.6 82.0 

268.0 152.3 168.5 160.6 



40 + 105.5 73.1 84.5 64.5 

It will be noticed by the table that cancer of the stomach 
and liver in males up to the age of fifty and females up to 
the age of forty is more frequent in the colored than in the 
white race, but on the average after the age of forty it 
is distinctly more common in the white race. These 
figures, which agree in general with the statements of 
other writers, would indicate that the usual observation 
that cancer is somewhat less prevalent in the colored 
than in the white race, is true of cancer of the stomach . 

Traumatism. — It is generally accepted that cancer 
may follow and be the direct result of traumatism and 
it cannot be denied that a cancer of the stomach may 
result from such a cause. Carcinoma, however, is the 
result of frequently repeated injuries and not usually 
of a single injury. It is difficult to see how the stomach, 
protected as it is in the abdominal cavity, can receive an 
external injury that results in the formation of a cancer, 
and it is doubtful if it often occurs. This agrees with 
the practical experience of other writers. Lockwood 
mentions no cases of his own but quotes one or two cases 
from Osier, which, as he himself points out, were doubtless 
cases of preexisting cancers without apparent symptoms 
previous to the injury. 

From the inside the stomach is doubtless subject to 
the frequent repeated injury that is known in other 
parts of the body to cause malignant growths. It is easy 
to appreciate that rough, undigested pieces of food, passing 
through the pylorus can be a source of repeated injury 
to the mucous membrane and produce a malignant growth. 



ETIOLOGY 217 

A gastric ulcer may be irritated by food, or it may be 
repeatedly injured by the movements and the changes 
in size of the stomach, and converted into a malignant 
growth. This may be in the realm of speculation, but by 
analogy with the formation of cancer in other parts of 
the body, it is probably the explanation of the formation 
of some gastric cancers. Fenwick speaks of cases in which 
a cancer has developed as the result of foreign bodies 
embedded in the stomach wall. 

Gastric Ulcer. — The relationship that a gastric ulcer 
bears to a gastric cancer has long been a topic of special 
interest. That a gastric ulcer may change from a benign 
to a malignant condition is strongly suggested though 
not proven by comparison with external ulcerations. 

It is known that an ulceration of the cheek constantly 
irritated by a tooth, an ulcer of the lip by smoking or 
of the anus by the passage of hard feces, may change its 
character and become malignant. In fact, there is prob- 
ably no external ulceration of which there are not examples 
in the literature, in which the benign character changed 
as a result of a continued irritation, to a malignant 
neoplasm. It should be accepted beyond question that 
an internal ulceration may change in the same way, and 
that a gastric ulcer may become a gastric cancer. 

It is more difficult to determine the percentage of cases 
of gastric ulcer that change to gastric cancer, and also 
the percentage of cases of gastric cancers which develop 
in a preexisting ulcer. It is an interesting observation 
that the percentages which are given by different writers 
are constantly increasing. The earlier writers estimated 
the number of cases of gastric carcinoma, which were 
preceded by gastric ulcer, to be 3 to 5 per cent. 

Smithies from a study of 566 consecutive cases of 
gastric tumor, which came either to operation or autopsy 
at the Mayo Clinic, found that 41.8 per cent, gave the 
early symptoms of chronic gastric ulcer; 18.7 per cent, 
gave the symptoms of "irregular" gastric ulcer, that is, 
gave early gastric symptoms which could not be con- 



218 CANCER OF THE STOMACH 

sidered to certainly indicate ulcer; and 32.1 per cent, 
gave the symptoms of gastric cancer without a history 
of previous gastric symptoms. 

Wilson, also from the Mayo Clinic, reports the result 
of a series of 530 cases of gastric cancer which came 
either to autopsy or operation, which were studied in- 
dependently by the clinician and the pathologist. In 
235 cases, that is, in about 45 per cent., the clinical 
and pathological diagnosis of gastric cancer on previous 
gastric ulcer were in exact agreement. In 60 per cent, 
the pathological diagnosis was cancer on previous ulcer. 
In the remaining 40 per cent, there were included a number 
of cases so far advanced that evidence of possible previous 
ulcer was obliterated. 

While^ these percentages have not been confirmed by 
other observers and are not generally accepted, the fact 
that a gastric ulcer is an important factor in the pro- 
duction of a gastric cancer must be recognized, and the 
importance of curing the pre-cancerous lesion, that is, 
the gastric ulcer, in order to avoid a possible malignant 
growth should be more generally accepted. 

The figures given above refer to the frequency with 
which a gastric cancer develops on a previous gastric 
ulcer; they do not, however, give any idea of the frequency 
with which a gastric ulcer changes to a gastric cancer. 
Statistics showing the frequency of the change do not 
exist, and with our present means of diagnosis, it would 
be practically impossible to obtain them. The medical 
diagnosis of gastric ulcer must always be more uncertain 
than the surgical diagnosis of gastric cancer confirmed 
by operative or postmortem findings. It must also be 
remembered, as Lockwood has pointed out, that the 
clinical experience of a surgical clinic, to which patients 
go only after exhausting all other resources, is different 
than that of a medical clinic to which many cases go and 
receive permanent relief. Lockwood, without having 
exact figures to substantiate his general impression, ex- 
presses the belief that not more than 3 or 4 per cent, of 



PATHOLOGY 219 

his cases of ulcer of the stomach subsequently develop 
a gastric carcinoma. 

Pathology. — Types. — The two principal types of car- 
cinoma of the stomach are the adenocarcinoma and the 
scirrhus. The adenocarcinoma is the more frequent type, 
it grows more rapidly and forms metastases earlier than 
the scirrhus. It may project into the lumen of the stomach 
as a cauliflower growth, or it may break down forming an 
ulcer. The scirrhus carcinoma is made up more largely 
of fibrous tissue and is of more slow growth. It is fre- 
quently the type that causes pyloric stenosis. Ulcera- 
tion is frequent but less so than in the adenocarcinoma. 
Colloid carcinoma is a form of degeneration which may 
be seen in either of the other two varieties. A carcinoma 
of the organ may be circumscribed and limited to a part 
of the stomach, or it may be diffuse involving most of 
the stomach. In the latter case the walls of the stomach 
are thick and rigid and the cavity reduced in size. 

Extension. — The extension of carcinoma of the stomach 
may take place in any of the following ways: 

1. By continuity of tissue. 

2. By contiguity of tissue. 

3. Through the lymphatic system. 

4. Through the vascular system. 

5. By peritoneal transplantation. 

1. By continuity the growth extends until it involves 
most or all of the stomach. At the cardiac end it may 
extend to the esophagus. Fenwick reports the direct 
invasion of the esophagus in 4.5 per cent, of his series of 
131 cases. Probably many cases diagnosed as carcinoma 
of the cardia, particularly those which come to autopsy 
or are seen only after the process is well advanced, are 
in reality primary in the esophagus with extension to the 
stomach. 

Extension of carcinoma of the stomach to the duodenum 
is even less frequent than the extension to the esophagus. 
Fenwick reports it in 1.5 per cent, of involvement of the 
duodenum in 131 cases. The infrequency of this extension 



220 CANCER OF THE STOMACH 

to the duodenum is an interesting observation in the 
action of cancer and may be due to anatomical conditions, 
as suggested by Fenwick, or to the influence of duodenal 
secretions, as has been suggested by others. Usually 
carcinoma respects no anatomical divisions, but extends 
over the nearest tissues. The influence of duodenal 
secretions in the prevention of the growth of cancer is 
an interesting hypothesis. It is not proven, but the 
infrequeney of primary cancer of the duodenum, which 
is an acknowledged fact, indicates that there is some at 
present unknown protective agency which limits the 
growth of a carcinoma in that organ. 

A carcinoma of the stomach begins in the mucous 
membrane and from there extends to involve the sub- 
mucous and muscular coats and finally the peritoneum. 

2. Extension by contiguity means the extension to 
other organs and structures, situated near the stomach 
but not normally adherent to it. As the growth of the 
gastric cancer nears the peritoneum, either through an 
inflammatory action or the irritation of the growth itself, 
adhesions are formed between the stomach and neighbor- 
ing organs, and through these adhesions the growth extends 
to other organs. The pancreas, which is normally in con- 
tact with the posterior wall of the stomach, is the organ 
most frequently involved. Fenwick reports the pancreas 
involved in 16.7 per cent, of his 131 cases. A part of 
these, however, was the result of extension through the 
lymph or bloodvessels and not all by contiguity. Next 
to the pancreas the liver is the organ most frequently 
involved by extension by contiguity. It was involved 
in 13.7 per cent, of Fenwick's cases. It is not so closely 
in contact over a large area as the pancreas but is more 
directly connected by blood and lymph vessels. The 
constant movement of the liver with the respiration may 
interfere with the formation of adhesions. Fenwick also 
reports the colon involved in 5.3 per cent, and the spleen 
in 3.7 per cent, of his series of cases. 

3. The extension of a carcinoma through the lymphatic 



PATHOLOGY 221 

vessels is the most important from the surgical standpoint. 
It is the earliest form of extension by which structures 
outside of the stomach are involved, and is usually the 
only one that there is any hope of counteracting by 
surgical interference. When the pancreas, liver, or other 
organs are involved by contiguity or otherwise the case is 
obviously inoperable. Such, however, is not the case with 
all lymphatic involvement. In the early stages, the spread 
of the carcinoma through the lymphatic vessels is checked 
by the lymphatic glands. Some of the carcinoma cells 
are doubtless destroyed in the glands, others live and 
involve the glands. The extent to which the lymphatic 
glands of the stomach are involved in gastric cancer, has 
a definite influence on the immediate and remote prognosis 
of the case and an intimate study of them is of the greatest 
importance. MacCarty and Blackford have examined 
microscopically a large number of glands removed from 
200 resected specimens of gastric carcinoma at the Mayo 
Clinic. They have expressed their findings and conclusions 
as follows: 

"The negative conclusions may be summarized as 
follows: 

" 1. The size of regional lymphatic glands bears no 
apparent relation to the size of the primary lesion in 
the stomach. 

"2. The size of a lymphatic gland is no criterion of the 
presence or absence of carcinoma. 

"3. Gross diagnoses of lymphatic glands are of no 
value except in advanced carcinoma of the glands. 

"4. The duration of symptoms bears no apparent 
relation to the size and extent of involvement in the 
lymphatic glands. 

" 5. The average age at operation and sex bear no direct 
relation to the glandular involvement. 

"The positive conclusions may be summarized as 
follows: 

" 1 . The average loss of weight increases with the 
increase in extent of glandular involvement. 



222 CANCER OF THE STOMACH 

"2. The immediate hospital postoperative mortal- 
ity is in direct proportion to the amount of glandular 
involvement. 

"3. The subsequent mortality is in direct proportion 
to the amount of glandular involvement. 

"4. Carcinomatous glandular involvement is very 
often microscopic. 

"5. The surgeon who desires to treat early carcinoma 
must depend upon the microscope in the hands of an 
experienced pathologist for early carcinomatous lymphatic 
involvement. 

"6. The diagnosis of early carcinomatous involvement 
requires extensive experience in the study of the so-called 
precarcinomatous reaction of lymphatic glands." 

This study of MacCarty and Blackford is of special 
value because it is based on a careful microscopic exami- 
nation of a large number of lymphatic glands, removed 
from cases of gastric carcinoma which were still operable. 
The findings prove scientifically for carcinoma of the 
stomach, the clinical impressions held by surgeons in 
regard to the involvement of lymphatic glands by ulcer- 
ated malignant growths. A carcinoma of the stomach is 
prone to break down and ulcerate as any carcinoma 
located externally or in the wall of a hollow viscus. It is 
then infected by the common pyogenic organisms and 
the neighboring glands may be enlarged as the result of 
this infection and not necessarily by the carcinoma. It is 
easy also to understand theoretically the cause of the 
increased immediate and remote mortality associated 
with the greater number of glands, because the greater 
the number of glands the more extensive must be the 
operation to remove them, and the more likely that some 
may be overlooked or inaccessible to operative removal. 
In general a larger number of involved glands indicates 
greater malignancy and therefore greater risk of recurrence. 

Next to the perigastric glands, those of the mediastinum 
and diaphragm are most frequently diseased. The 
supraclavicular glands are involved and palpable, the 



PATHOLOGY 223 

left more frequently than the right, in about 4 per cent, 
of the cases. In addition to the lymphatic glands, any 
organs may be involved through the lymphatic system. 
The liver, the pancreas, the peritoneum and intestines, 
the lungs and pleura, in the order named, are the organs 
most frequently involved with metastatic deposits. 

4. Extension through the blood system is less frequent 
than through the lymphatic vessels. The veins are more 
frequently involved than the arteries. The malignant 
growth may involve a vein and ulcerate into its lumen. 
The cancerous cells are then carried by the blood to any 
part of the body. The bloodvessels of the stomach com- 
municate directly with the portal system and therefore 
the liver is the organ most often affected. The cancer 
cells may enter the general venous system by direct 
involvement by one of the systemic veins, or by the second- 
ary involvement from a growth in the liver, or indirectly 
through the lymphatic system. After the general vascular 
system has been invaded, the dissemination of the disease 
through the system is rapid. 

5. Extension by peritoneal transplantation occurs only 
after the growth has advanced sufficiently to involve the 
peritoneal covering of the stomach. Free cancer cells, 
or pieces of malignant tissue, are separated from the 
growth, and these either by gravity or by the movement 
of peritoneal fluids are scattered over the general peritoneal 
cavity. A metastatic deposit on the anterior surface of 
the rectum produced by peritoneal transplantation is 
reported by Palmer to have been found in 6.5 per cent, 
of a series of 4.35 cases of carcinoma of the upper abdominal 
cavity, and to have been one of the means of determining 
the cases to be inoperable. Such a growth is usually 
located on the anterior surface of the rectum, above the 
prostate gland in the male, and above and behind the 
uterus in the female. Jt begins of course from the peri- 
toneal surface of the rectum, and, as is shown by the 
proctoscope, it docs not involve the rectal mucous mem- 
brane. The condition may occur secondarily to carcinoma 



224 CANCER OF THE STOMACH 

of any organ after the peritoneum has been involved if 
the patient is still up and about. Gravity favors the 
deposit in the lower part of the peritoneal cavity. 
Obviously a growth so far advanced that a metastatic 
deposit is found at such a distance from the primary 
growth and in such a manner, is beyond successful opera- 
tive removal. 

Location of the Growth. — The location at which the tumor 
starts in the stomach has a definite bearing on its early 
symptoms and its treatment. The pylorus and lesser 
curvature of the stomach are most frequently involved 
first and the cardia next. The following percentages from 
Patterson show the location of the growth in 168 con- 
secutive postmortem cases of gastric carcinoma: 

Pylorus 61.3 per cent. 

Lesser curvatures 14.2 

Cardiac orifice 5.9 " 

Anterior wall 5.3 

Whole stomach 4.7 

Central 4.1 

Posterior surface 4.1 

These figures correspond closely to those of other 
observers who have made their statistics from postmortem 
examinations. At this stage, the growth is often so far 
advanced that it is impossible to determine surely at 
what point the growth commenced. Statistics from 
surgical operations therefore are of greater accuracy. 
Surgical statistics show a larger percentage of cases 
starting in the lesser curvature but close to the pylorus. 
They also show a larger number as starting in the cardia 
than is indicated in the above figures. 

Symptoms. — Onset.— In regard to the onset of symptoms 
cases of carcinoma of the stomach may be divided into 
four classes. 

1 . Those cases which give no symptoms until the disease 
is far advanced. 

2. Those cases with a sudden onset following an error 
in diet, overexertion, traumatism or some unknown 



SYMPTOMS 225 

cause. In the case with this onset, the incident which 
starts the symptoms, should not be considered the cause 
of the cancer. It is more probable that the cancer 
already existed, but on account of its location, or period or 
extent of the growth, had not given subjective symptoms 
sufficient to be noticed by the patient. The trauma or 
attack of acute gastritis, was sufficient to start abrupt 
symptoms which otherwise would have been present soon 
but which would have developed more slowly. This 
onset of carcinoma of the stomach is quite common. 

3. Those cases with a gradual onset and a progressive 
and rather rapid course but without history of previous 
gastric disturbances. 

4. Those cases with a long previous history of gastric 
ulcer, or other chronic disease of the stomach. It is 
accepted as a fact, that a carcinoma of the stomach may 
develop in an ulcer of the stomach, and it is natural 
to expect that the symptoms of the cancer of the stomach 
would be preceded by the symptoms of the gastric ulcer. 

Early Symptoms. — As in all other internal cancers, that 
of the stomach may develop to an advanced stage before 
it gives signs or symptoms, that suggest trouble to the 
patient, or can be easily diagnosed by the expert clinician. 
Before giving any evident or marked symptoms, it may 
have passed the operable stage, and reached one for which 
nothing other than a palliative operation or the medical 
treatment of individual symptoms can be done for the 
patient. The cases of carcinoma of the stomach, in which 
the growth is located near the cardiac orifice, are more 
likely to give no early symptoms than those situated 
elsewhere, as they do not early interfere with its motility 
and digestive functions. In other cases, the early symp- 
toms of gastric cancer are mistaken for those of some 
other disease. Fortunately cases of this class will become 
less numerous as physicians understand better and use 
more frequently the modern methods for the diagnosis of 
gastric diseases, and as the laity learns the possible 
significance of the symptoms of dyspepsia and gastric 
15 



226 CANCER OF THE STOMACH 

disturbances, the importance of an early diagnosis and 
appropriate treatment, and the encouraging results of 
operation. 

The early symptoms are usually pain or discomfort in 
the epigastric region, loss of appetite, vomiting, loss of 
flesh and strength. 

Pain. — This is usually one of the early and most 
constant symptoms of cancer of the stomach. It is 
apt to be continuous but with exacerbations, and to 
increase in severity as the disease progresses. In char- 
acter it is less short and severe than the pain of gastric 
ulcer and more of a dull, boring type. In some cases, it 
is more of a discomfort or distress than actual pain. 
The pain of gastric cancer is less influenced by the intake 
of food than that of gastric ulcer. More cases, however, 
have an increase of pain after the injection of food than 
do not. In gastric cancer there is usually constantly 
present some pain or discomfort and there are frequent 
exacerbations. These exacerbations of pain may come 
on a few minutes or some hours after taking food or may 
not be influenced by food at all. Lockwood considers that 
it is a point of diagnostic value that the pain of cancer 
of the stomach is less influenced by a mild bland diet than 
that of gastric ulcer. He considers that pain that persists 
after a week of peptonized milk is more likely to be caused 
by a cancer than an ulcer of the stomach. 

Absence of pain is noted in a considerable percentage of 
cases of cancer of the stomach. Of Lockwood's hospital 
cases 21 per cent, and of his private cases 15 per cent, 
were free from pain. Graham reports 14 per cent, either 
free of pain or with only slight distress. It is probable, 
however, that before the termination of the disease many 
of these cases would develop pain and the actual number 
free of pain during the entire course of the disease is much 
less. 

When pain starts, it usually continues and increases in 
severity. It may be relieved in rare instances by the 
natural formation of a gastro-intestinal fistula. This 



SYMPTOMS 227 

would mean that the growth had extended through the 
wall of the stomach and had become adherent to a coil 
of the intestine and that the intervening septum had 
sloughed allowing the stomach contents to pass into the 
intestine without passing through the pylorus. Such 
an outcome would be most unusual and would occur 
only late in the course of the disease. It might relieve 
the pain caused by the passage of food through the pylorus 
but there would be considerable pain from the peritoneal 
involvement. If there is a narrowing of the cardiac 
orifice of the stomach by the growth, there may be dis- 
comfort or pain with deglutition without pain at other 
times. With a growth at the pylorus on account of the 
stenosis, sharp cramp like pains due to forcing the stomach 
contents through the narrow opening are common. In 
any of the typical locations, the growth may be painless. 

The localization of the pain of gastric carcinoma is more 
indefinite than that of gastric ulcer and is also more 
diffuse. Most frequently the pain of carcinoma is located 
in the epigastrium. The pain may be referred to the 
lower end of the sternum, to the chest, to the shoulder or 
to the lower abdomen. Radiation of the pain suggests 
peritoneal involvement. 

Vomiting. — Vomiting is a frequent symptom of cancer 
of the stomach. Graham gives it as a symptom in 60 
to 70 per cent, of the cases. Lockwood noted it in 80 
per cent, of his hospital cases, and 65 per cent, of his 
private cases, and explains the difference by the probable 
difference in the stage of the disease and attention to 
the diet. That is, that the private cases were seen 
;it an earlier stage of the disease than the hospital cases. 
Probably at a still later stage, a larger percentage even 
of the hospital cases would give vomiting as a symptom. 
In the earlier stages of the disease vomiting is less frequent 
ami less constant. It may be started by some error in 
diet and then when once started, be constant during the 
course of the <li>ease. It occurs most frequently at an 
indefinite time varying from a few minutes to some hours 



228 CANCER OF THE STOMACH 

after eating. It is more indefinite as to the time of its 
occurrence than ulcer of the stomach and does not give 
the same relief to pain. The pain may be increased by 
vomiting. 

The location of the growth has some effect on the time and 
occurrence of the vomiting. If the growth is situated at the 
cardiac orifice of the stomach, the vomiting may be more 
of the nature of a regurgitation of food. There is trouble 
in taking food, at first solid and later even liquids pass 
the cardia into the stomach only with difficulty. When 
the growth is situated at the fundus of the stomach vom- 
iting is apt to appear late and to be less constant as a 
symptom. If situated at the pylorus, vomiting is nearly 
sure to begin with the stenosis and, if the latter is asso- 
ciated with gastric dilatation, may be in considerable 
quantity and at long intervals. Vomiting is apt to be an 
early symptom and in small quantity in the case of diffuse 
carcinoma of the stomach. 

The character of the vomitus varies with the stage of 
the disease. In the early stages it is composed of food, 
more or less recently taken, partially digested and mixed 
with mucus. Later after the growth has ulcerated and 
broken down the vomitus also contains the discharges 
from the growth. It usually contains blood in varying 
amount. There may be occult blood which can be detected 
only by careful examination of the vomitus or blood that 
can easily be seen, or even blood in such amount that the 
life of the patient is jeopardized by its loss. A fatal 
hemorrhage, however, occurs from carcinoma of the 
stomach only rarely. Rarely pieces of the growth itself 
are vomited and are of positive value in making the 
diagnosis. In an established case the vomitus is dark 
brown in color, it has a foul, disagreeable odor, as would 
be expected from an ulcerated carcinoma, and is com- 
posed of food largely undigested and mixed with blood, 
mucus, and the gastric juices. In some cases the vomited 
matter has distinctly a fecal character. This suggests 
that the intestinal contents have entered the stomach, 



SYMPTOMS 229 

possibly through a pylorus that is rigid and open or 
possibly through a gastro-intestinal fistula. 

The amount of the vomitus has a relationship to the 
size of the stomach. If there is a large amount, it is 
suggested that there has been a dilation of the stomach 
probably from a stenosis of the pylorus. 

Appetite. — Loss of appetite is an early and a frequent 
symptom of cancer of the stomach. Graham noted it 
in 60 per cent, of his cases. Often it is the first symptom 
to attract the notice of the patient. It may be for all 
food but is often for meat only. 

Cachexia. — Loss of weight and strength are often 
important factors in the diagnosis of cancer of the stomach. 
The loss of weight and of strength is partly due to the loss 
of appetite and to interference with the functions of the 
stomach and partly to the absorption of the cancer toxins. 
These symptoms are usually early and progressive regard- 
less of medical treatment, though there may be a tem- 
porary improvement of both. There is usually a distinct 
improvement after a gastroenterostomy, but this also 
would be only temporary. The loss of flesh and strength 
may be the only symptom of which the patient complains, 
and cancer of the stomach only found after a careful 
detailed examination. Occasionally the interference with 
weight and strength does not occur until late in the course 
of the disease. Naturally these cases are the ones in 
which there has been the least interference with the 
appetite and the functions of the stomach, and in which 
there has been the least toxic absorption from the cancer- 
ous growth. 

Bowels. — There is no direct connection between the 
condition of the bowels and the growth in the stomach. 
In the early stages of the disease when the functions of 
the stomacb have been only slightly disturbed, the bowels 
are regular. If there is marked pyloric stenosis so that 
only a small amount of food passes from the stomach to 
the intestines, constipation is usually present. The same 
is often the ease when on aeeount of loss of appetite 



230 CANCER OF THE STOMACH 

only a small amount of food is taken. In other cases, 
there may be diarrhea or alternating constipation and 
diarrhea. 

The presence of blood in the movements will be discussed 
elsewhere. 

Blood.— The condition of the blood in gastric carcinoma 
differs somewhat from that usually found in cases of 
malignant tumors due probably to interference with the 
function of the stomach. In the early stages, there may 
be no changes in the blood. Later with the ulceration and 
bleeding of the growth and disturbance of the gastric 
functions, anemia is usually present. At first on account 
of the vomiting or limited intake of fluids, there may be 
a concentration of the blood and a corresponding increase 
in the number of red blood cells. Lockwood reports over 
5,000,000 red blood cells in 8.7 per cent, of the cases. With 
this increase in the number of red blood cells there may be 
a low percentage of hemoglobin; that is, the percentage 
of hemoglobin decreases earlier and more rapidly than 
the number of red blood cells. Later in the majority of 
cases both as to hemoglobin and red blood cells, the blood 
gives the picture of marked secondary anemia. There is a 
Class of cases of cancer of the stomach in which the blood 
picture closely resembles that of pernicious anemia. 

A moderate polynuclear leukocytosis is present in most 
cases after the first stage. It is dependent largely on the 
ulceration and hemorrhage from the growth and the 
inflammation about it and on the metastases. 

The absence of digestion leukocytosis has been noted 
by a number of writers. This has been noted for other 
gastric lesions, such as ulcer and pyloric stenosis, and 
also in some constitutional disturbances. It will have 
been seen that in the blood picture, either in the red or 
in the white cells, that there is nothing of more than a 
suggestive value. 

Hemorrhage in Cancer of the Stomach. — Bleeding in a 
cancer of the stomach is one of the most common symp- 
toms. It is usuallv divided into visible and occult bleed- 



SYMPTOMS 231 

ing, and the blood may be found either in the stomach 
contents or in the feces. The constant presence of blood 
in either the stomach contents or in the feces of late 
years has been considered a most important diagnostic 
aid in cancer of the stomach. 

Visible bleeding occurs in about 25 per cent, of the 
cases of gastric cancer. It may be vomited as a coffee- 
ground fluid or it may enter the intestine and be passed 
in the feces as tarry stools. In a small percentage of cases, 
probably on account of the ulceration of a large vessel, 
bright red blood may be vomited and the loss of blood 
may be sufficient to cause the death of the patient. 

Occult bleeding is much more frequent than visible 
bleeding. Repeated examinations of stomach contents 
and of the feces will show occult blood in nearly every 
case. Care must be taken, in the examination for occult 
blood, to exclude other sources of blood as far as possible. 
In the examination of gastric contents for occult blood, 
bleeding from the mouth or gums and injury to the esopha- 
gus with the stomach tube are sources of possible error. 
In the examination of feces for occult blood, hemorrhoids, 
benign ulcerations of the gastro-intestinal tract, as well 
as certain constitutional diseases such as hemophilia and 
typhoid fever must also be considered. While thoroughly 
cooked meat does not interfere with tests, it is best to 
exclude all meat for two days previous to the time of 
examination. 

If no occult blood is found on repeated examinations 
of the gastric contents and feces, there is probably no 
cancer present. If occult blood is constantly demonstrated 
on repeated examinations, particularly if the patient has 
been on a bland or milk diet, it is strongly suggestive of 
cancer. The occult blood of gastric ulcer is usually inter- 
mittent and usually disappears by proper diet. The 
occult blood of cancer is usually persistent regardless of 
diet. The presence or absence of occult blood, therefore, 
is of great diagnostic importance, but repeated examina- 
tions are necessary. 



232 CANCER OF THE STOMACH 

Tumor. — A palpable tumor was present in 67 per cent, 
of the cases in a series of 1000 cases of gastric carcinoma 
at the Mayo Clinic. The detection of the tumor in car- 
cinoma of the stomach depends on the size of the tumor, 
the location of the tumor, and the condition of the patient. 

Naturally the smaller the growth, the more difficult 
it is to detect it. It is, however, at this stage that its 
discovery is of the greatest importance as the earlier the 
tumor is found, the greater the chances of its still being 
in an operable stage. There is little to be gained by finding 
a tumor late in the course of the disease. 

Tumors located in the cardia, in the fundus, in the 
posterior wall and in the lesser curvature are the most 
difficult to detect and in these locations may not be felt 
even when of large size. Tumors of the pylorus are the 
most easy to palpate unless they are adherent behind the 
liver. A thin relaxed abdominal wall and a prolapsed 
stomach favor the palpation of gastric tumor. A rigid or 
thick abdominal wall, a stomach that is adherent high and 
the presence of ascites tend to obscure a tumor. 

The location of a tumor of the stomach is subject to 
wide variation. Most frequently the tumor is located 
in the umbilical or epigastric regions. The following 
table gives the location of cases as reported by Lockwood : 

Umbilical region 38 per cent. 

Epigastric region 25 " 

Right hypochondriac region 19 " 

The location of the tumor is influenced by respiratory 
movements, and by changes in size and position of the 
stomach due to distention either by food or for diagnostic 
purposes. 

Unless adherent to a fixed organ, the tumor usually 
moves with respiration. Absence of adhesions to the liver 
is indicated, if at the end of a forced inspiration, which 
pushes the liver and tumor downward, the tumor can be 
grasped and held while the liver recedes. 

If freely movable, there are certain changes in position 



^>, 



SYMPTOMS 233 

due to distention of the stomach. Tumors of the pylorus 
move downward and to the right. Tumors of the lesser 
curvature are apt to become less prominent and those 
of the greater curvature more prominent with distention 
of the stomach. 

The mobility of the tumor is determined by its location 
in the wall of the stomach, and by the adhesions between 
it and other organs. If the organ to which the tumor is 
adherent is itself movable, the tumor of course would be 
also. If the tumor is adherent to the abdominal wall 
or to the pancreas it is not movable. If it is adherent 
to the liver it moves only with the liver, that is, with 
respiration. The opposite does. not necessarily follow. 
A tumor may move only with the liver but not be adherent 
to it. If it is adherent to the colon or to the small intes- 
tines, its mobility is only slightly limited. 

The mobility of the tumor is an important factor in 
determining the prognosis. A movable tumor indicates 
that the case is still operable. A fixed tumor suggests 
that the case is not operable. Neither statement is with- 
out exceptions. A tumor may be fixed by adhesive in- 
flammation during the operable stage. A movable tumor 
may be inoperable on account of metastases, enlarged 
glands, or the extent of the growth. 

Analysis of the Stomach Contents. — Examination of the 
stomach contents, revealing as it does the changes in 
the motor and secretory powers of the stomach and 
their influence on gastric digestion, is an important aid 
in the diagnosis of gastric cancer but, with the rare 
exception of a piece of the tumor itself, there is nothing 
pathognomonic in the findings. 

Motor insufficiency is present usually early in most 
cases of cancer of the stomach. It may be due to the 
pyloric stenosis, or to the weakening of the muscle wall 
from toxemia, or to the infiltration of the walls of the 
stomach by the growth. When the motor insufficiency 
i-, marked, food, particularly solids, may remain in the 
stomach for a number of days. In cancer of the cardia 



234 CANCER OF THE STOMACH 

and the lesser curvature it is less marked than when the 
growth is in the pylorus or other parts of the stomach. 

There may or may not be dilation of the stomach 
with the motor insufficiency. Lockwood believes it to be 
less frequent and less marked than in simple stenosis of 
the pylorus. It is, however, frequently present. 

The most frequent changes in the secretory power of 
the stomach in gastric cancer is the absence of free hydro- 
chloric acid. This, however, is not pathognomonic nor is 
it a constant finding. The absence of free hydrochloric 
acid was found in 56 per cent, of Graham's and in 52 
per cent, of Lockwood's cases; but if present, it was 
usually reduced in quantity. Free hydrochloric acid may 
be absent in gastric neurosis and atrophy and in certain 
constitutional diseases, and is therefore not pathogno- 
monic. The continued absence of free hydrochloric acid 
is, however, strong evidence of the presence of cancer of 
the stomach. The absence of the free hydrochloric acid in 
carcinoma of the stomach is due partly to the diminution 
of the amount secreted and partly to the combination of 
that which is secreted with products of the cancer. 

Lactic acid is the organic acid most frequently found in 
carcinoma of the stomach. It is dependent on the diminu- 
tion of hydrochloric acid and the presence of undigested 
albuminous food. A small amount of hydrochloric acid 
checks lactic acid fermentation, and as hydrochloric acid 
is often present in gastric carcinoma, the absence of lactic 
acid does not prove that cancer is not present. Lockwood 
reports that lactic acid, either alone or with hydrochloric 
acid, was present in 64 per cent, of his series of cases 
after the test breakfast. Other writers have found it 
present in a large percentage of cases. 

Roentgen-ray Examination. — Roentgenology is a material 
aid in the diagnosis of cancer of the stomach. Its value 
consists in enabling the roentgenologist to detect certain 
mechanical and functional changes that exist in the 
stomach as a result of the malignant growth, and by the 
proper interpretation of the findings not only to assist 






ROENTGEN-RAY EXAMINATION 235 

in making the diagnosis of gastric cancer, but also in 
determining the location and extent of the growth, and 
the advisability of operative interference. A growth 
involving the cardia would be considered to be inoperable 
either for removal or for a gastroenterostomy. An 
extensive or a diffuse growth might involve so great a 
portion of the stomach wall, that sufficient room for a 
gastroenterostomy might not remain. These facts can 
sometimes be determined by away examinations, and by 
no other non-operative methods. 

Carman states that at the Mayo Clinic, 93 per cent, 
of the cases of gastric cancer give diagnostic signs. He 
gives the following radiological signs of carcinoma of the 
stomach, arranged in the order of their relative importance : 

1. Filling defects. 

2. Altered pyloric function. 

(a) Gaping of the pylorus. 

(b) Obstruction of the pylorus. 

3. Advanced position of the six-hour meal. 

4. Absence of the peristaltic wave from the involved 
area of the stomach. 

5. Diminished mobility and loss of flexibility. 

6. Diminution in the size of the stomach. 

7. Antiperistalsis. 

1. The filling defect is a sign of greatest importance. 
It depends of course on the absence of shadow of the 
bismuth meal in the part of the cavity of the stomach 
occupied by the growth. The location, the size and the 
irregularity of contour of this light area indicate the 
location, the extent and nature of the growth. The light 
area projecting into the stomach shadow may be a large, 
rounded area with regular contour and such a condition 
usually indicates a gastric cancer. It may be produced 
by change in the shape of the stomach by external pressure, 
as by a tumor of one of the surrounding organs, or by 
feces or gas in a colon not completely emptied before the 
examination. The latter condition is excluded if the 
stomach remains the same at subsequent examinations. 



236 CANCER OF THE STOMACH 

It is more difficult to exclude the pressure of external 
tumors, particularly if they are immovable. If they 
are movable relative to the stomach, manipulation and 
a subsequent .r-ray examination may give a different 
picture. That of a gastric cancer would usually be 
unchanged. More frequently the contour of the light 
area is irregular with shaded places in the shadow produced 
by the projections of an ulcerated irregular growth into 
the bismuth meal. Cole compares this light area to the 
appearance of finger prints. If the growth is annular, 
it may be indicated by a permanent change in the shape 
of the stomach as shown by the shape of the shadow. 
In the middle of the stomach, such a growth may produce 
an hour-glass stomach. A change in the outline of the 
stomach may be produced by a gastric spasm and its 
radiograph resemble that of a stomach contracted by a 
gastric cancer. Repeated examinations should differ- 
entiate between the two conditions. A diffuse carcinoma 
of the stomach may exist without any projections into 
the stomach cavity, and would cause no irregularity 
of the shadow. Such a stomach, however, would show 
interference with its normal peristaltic action and possibly 
also change in its size and shape. 

2. The function of the pylorus may be altered in two 
opposite directions. It may be narrowed and stenosed, 
or it may remain permanently open and patent. The 
stenosis of the pylorus is caused by the encroachment and 
the contraction of the growth and is shown by the narrow 
bismuth shadow in the .r-ray plate. The open pylorus 
may be caused either by infiltration and destruction of 
the pyloric tissues or by the decreased acidity of the 
stomach contents. The open pylorus is of course shown 
by an abnormally broad bismuth shadow in the a>ray 
plate. 

3. In addition to the radiographic picture of the pylorus, 
the condition of the pylorus is indicated by the position 
of the six-hour meal. With an obstructed pylorus at the 
end of six hours there will still be a residue in the stomach. 



DIAGNOSIS 237 

The stomach itself may or may not be dilated. Ordinarily 
the head of a bismuth meal at the end of six hours is about 
at the cecum. In carcinoma of the stomach, due to hyper- 
motility from the diminution of acidity it is often found 
at or beyond the splenic flexure. 

4. The peristalsis of the stomach may be influenced 
in three ways by a gastric carcinoma. The peristaltic 
wave may be decreased by the diminution in acidity, it 
may be increased by the action of the stomach in over- 
coming the pyloric obstruction, it may be made irregular 
by the presence of the growth in the stomach wall. The 
last of these three is the most important. 

5. Diminished mobility might indicate extension of the 
growth from the stomach to surrounding organs or to 
the abdominal wall. The impossibility of changing the 
position of the tumor or stomach by manipulation would 
be shown on the .r-ray plate. 

6. The diminution in size of the stomach without 
marked change in shape is sometimes found in a gastric 
carcinoma of the diffuse infiltrating type. 

Diagnosis. — As has been repeatedly indicated, the 
only positive diagnosis of gastric carcinoma is the micro- 
scopical examination of a piece of the growth. Excepting 
in rare instances, this is never possible except after 
operation or autopsy. The combination of the individual 
symptoms is usually sufficient to establish the diagnosis 
more accurately than most abdominal conditions are 
diagnosed, and the lesions for which it is most frequently 
mistaken are lesions for which an abdominal operation 
is indicated. 

The first symptom of value in establishing the diagnosis 
is the presence of tumor. A tumor is present in over one- 
half the cases and, reversely, most tumors in the upper 
abdomen are gastric carcinomata. Evidence of pyloric 
stenosis is shown by undigested food in the stomach 
following a test meal. The Roentgen-ray findings are of 
increasing value not only for diagnosis but for prognosis 
and treatment. The rinding at repeated examination 



238 CANCER OF THE STOMACH 

of occult blood in stomach contents or in feces even with 
the patient on a bland diet is strong indication of car- 
cinoma. The absence of hydrochloric acid and the presence 
of lactic acid are most frequently found. 

These symptoms, of importance probably in the order 
named, will usually establish the diagnosis of gastric car- 
cinoma. It will be noted that they are the result of a 
physical examination of the patient and of the laboratory 
findings and not of the subjective symptoms of the patient. 

Treatment. — The three possible results for which we 
treat any cancer are to cure the patient, to prolong life 
and to relieve symptoms, and these are the objective 
points in the treatment of a cancer of the stomach. 
There is no evidence that any cancer of the stomach has 
ever been cured except by surgical removal, and the only 
treatment therefore which is of permanent value to the 
patient is surgical. At the present time, the number of 
cases that are cured is small, though cancer is more 
frequent in the stomach than in any other organ. Ana- 
tomically the stomach in part is more favorably placed 
for the radical removal of a cancer than are other organs, 
such as the breast and uterus which come more frequently 
and successfully to removal for malignant growths. 
Partly from the anatomical structure and relations of the 
stomach, and partly from the pathological character of 
the growth, a gastric cancer remains relatively a long 
time as a purely local disease, limited to the stomach or 
to the stomach and the lymphatic glands in its immediate 
vicinity. This is a great advantage in the surgical treat- 
ment of gastric carcinoma as it lowers the operative 
mortality and increases the percentage of permanent 
cures. 

There are, however, certain obstacles which are difficult 
to overcome, and which are responsible for the small 
number of cured cases. The most important is that of 
early diagnosis. Some cases do not give evident symp- 
toms until the disease has passed the operable stage. In 
other cases, though symptoms are present, they are 



TREATMENT 239 

not sufficiently positive to compel an exploratory or other 
operation, and the patient is treated medically beyond 
the operable period. Another obstacle is the location, 
at the cardiac orifice, of tumors which cannot be removed 
by our present surgical technique. Another obstacle which 
is being gradually overcome is the feeling in the medical 
profession that the immediate and end results of gastric 
surgery are too unsatisfactory to urge an operation. 

There are certain symptoms that show definitely that 
a case is inoperable. They are marked ascites which 
indicates peritoneal or hepatic involvement that is beyond 
relief, cachexia, particularly if associated with a long 
gastric history, and evident metastases, which most 
frequently are in the supraclavicular glands, in the 
rectum, at the umbilicus, or in the liver. 

The treatment of cancer of the stomach will be divided 
into the treatment of 

1. Cancer involving the pylorus. 

2. Cancer involving the cardiac orifice. 

3. Cancer of the middle of the stomach. 

Under each of these divisions will be considered the 
treatment of (a) operable cases, that is, growths which 
can be removed, and (b) advanced cases, that is, cases 
on which no operation other than a palliative one can 
be performed. 

1. Cancer of the Pylorus. — (a) Operable Cases. — 
These are the most favorable cases of gastric cancer for 
operative treatment. This consists of a pylorectomy and 
partial gastrectomy; that is, the removal of the pylorus 
and a part of the wall of the stomach with the malignant 
growth. 

In the operation of pylorectomy and partial gastrectomy 
for carcinoma involving the pylorus of the stomach, 
about one inch of the duodenum is removed. As gastric 
carcinoma rarely extends on to the duodenum, this is 
usually sufficient. Of the stomach, that part which is 
situated at the right of a line drawn on the lesser eurYature 
as near the cardiac orifice as is technically possible to the 



240 CANCER OF THE STOMACH 

junction of the pyloric and middle thirds or to the middle 
of the greater curvature, is usually removed. This would 
include most of the lesser curvature and a third or a half 
of the greater curvature. The object of this wide removal 
is to include the lymphatic vessels and glands of the lesser 
curvature and those of the pyloric end of the stomach. 
There are but few lymphatics in the fundus of the stomach. 

In the past, with inferior surgical technique and late 
diagnoses, the immediate mortality and frequent early 
recurrences were against the operation. At present, 
the immediate mortality from the operation is materially 
lower and there is a larger percentage of cases that are 
alive at the end of five years. This is well shown by the 
statistics from the Mayo Clinic. Between the years of 
1897 and 1910, partial gastrectomy and pylorectomy was 
performed 266 times (244 times for gastric cancer), with 
a mortality of 12.4 per cent. During the year 1909, 
there were 46 such operations with a mortality of 8.6 
per cent. Patterson gives his mortality as about 14 per 
cent. These mortality percentages include cases over a 
period of years during which the technique of gastric 
surgery was in a formative stage and associated with a 
high mortality. With greater experience in gastric 
surgery and earlier diagnoses, the mortality has been 
lowered and until now it averages about 10 per cent, 
and in some clinics somewhat lower. This compares 
favorably with the operative mortality of carcinoma 
of the uterus or any other abdominal organ. 

In regard to end results Patterson reports about 15 
per cent, of the cases that recovered from the operation 
to be well at the end of five years. Mayo in a large 
series of cases, but including in part a more recent period 
than was covered by Patterson's series, reports that of 
the cases who recovered from the operation, 35 per cent, 
were well at the end of three years and 25 per cent, 
at the end of five years. These percentages are decidedly 
higher than the average results obtained for resection 
of the stomach for gastric carcinoma. It is Mayo's 



TREATMENT 241 

opinion that both the operative mortality and the end 
results will be further improved, not so much by better 
technique or more extensive operation as by earlier 
diagnosis. 

1. Cancer of the Pylorus. — (a) Advanced Cases. — 
The treatment of the advanced carcinoma of the pylorus 
of the stomach may be by a palliative partial gastrectomy, 
by a gastroenterostomy or entirely medical. 

The advocates of a palliative partial gastrectomy claim 
that there is greater relief from pain, and from toxemia 
due to the absorption of the products of the tumor changes, 
than by a gastroenterostomy and with only a slight 
increase in mortality. These conditions may obtain, but 
probably not often. The toxemia may not be a marked 
symptom as, for example, in a cancer of the scirrhus type, 
and the pain is usually relieved by a gastroenterostomy 
though possibly not with the same regularity as by a 
partial gastrectomy. The growth in the stomach wall 
may be definitely limited and easily removed, but the 
case may be an advanced and incurable one on account 
of metastatic deposits in the liver or other organ or 
irremovable lymphatic glands. Such a case might be 
suitable for a palliative partial gastrectomy as it would 
give more relief to the stomach symptoms than a gastro- 
enterostomy and with little increased risk. 

A gastroenterostomy is indicated and performed to relieve 
pyloric stenosis. By making an anastomosis between 
the stomach and the intestine beyond the obstruction, 
the stomach contents pass into the intestine without 
passing through the pylorus. This relieves the pain caused 
by the contraction of the stomach forcing its contents 
through the narrow pylorus, and also the pain caused by 
the irritation of the growth itself. A gastroenterostomy 
is not indicated as soon as a diagnosis of inoperable pyloric 
cancer has been made, but only when the symptoms of 
pyloric obstruction arc marked and not relieved by non- 
operative measures. If an advanced gastric carcinoma, 
which would probably ultimately cause pyloric stenosis, 

16 



242 CANCER OF THE STOMACH 

has been found by an exploratory celiotomy, it would be 
better to do the gastroenterostomy at that time rather 
than risk a second operation. 

The non-surgical treatment is medicinal, dietetic, and 
mechanical. If there is absence of hydrochloric acid, 
its administration may assist the digestion. Pepsin 
practically is found to be of value in some cases. If there 
is hyperacidity, alkalies either as bicarbonate of soda 
or alkaline waters should be given. Tonics may be of 
benefit to the general condition of the patient. Before 
the termination of the disease, opium in some form will 
be necessary to relieve the pain. It should be remembered 
that the duration of the disease may be prolonged, and 
therefore the use of opium should be reserved for the 
later stages. In the beginning, much can be accomplished 
to alleviate pain by diet and lavage. Aspirin at first 
alone, later combined with codein, and finally codein 
alone, will postpone the necessity of using morphin. 

The diet should be largely soft or liquid and with no 
coarse meats or vegetables. Food should be administered 
frequently and in small amounts. The total quantity, 
however, should be as liberal as the case will allow, in 
order to preserve the weight and general condition of the 
patient. The value of nutrient enemata is limited. If 
they are given frequently or over a long period, the rectum 
is apt to become irritated and be an additional cause of 
discomfort to the patient. Certainly fluids and probably 
some nourishment can be administered in this way. 

Lavage is of special value in the treatment of the 
gastric cancer which causes pyloric stenosis to remove the 
stomach contents that have not passed into the intestines. 
Beyond keeping the stomach clean, little or nothing can 
be accomplished by attempting to treat the ulcerated 
cancer itself. 

2. Cancer Involving the Cardiac Orifice. — The 
treatment of cancer of the cardiac orifice of the stomach 
is entirely palliative as the removal of the growth in this 
location is beyond our present surgical technique. The 



TREATMENT 243 

symptom requiring most attention is the progressively 
increasing dysphagia. At first this can be relieved by 
soft and later by liquid foods. The danger and short 
duration of any benefit derived from it, excludes any 
attempt to dilate the stricture or to feed through the 
stomach tube. If the dysphagia is too marked a gastros- 
tomy or a jejunostomy would be indicated. Lavage is 
excluded by the danger of passing the tube and because 
with the absence of pyloric stenosis there is ordinarily 
no indication for it. 

The general medicinal and dietary treatment of these 
cases is practically the same as for the cases with pyloric 
obstruction. 

3. Carcinoma of the Middle of the Stomach.— 
The treatment of an operable carcinoma of the middle 
of the stomach is practically the same as that for carcinoma 
of the pyloric orifice. In some cases the growth can be 
removed and the stomach resutured. The better operation 
is the partial gastrectomy and a gastro-enterostomy. 

In the advanced case on account of the obstruction of 
the growth, a gastro-enterostomy or if there is not sufficient 
room, a jejunostomy may be indicated. 

The general medical and dietary treatment is the 
same as has been described under carcinoma of the 
pyloric orifice. 

literature. 

Carman. Collected Papers, Mayo Clinic, 1913. 

Cole. New York Medical Journal, February, 1914. 

Fenwick. Lancet, 1901, i, 463. 

Graham. Collected Papers, Mayo Clinic, 1913. 

Lockwood. Diseases of the Stomach. 

Martin. Osier's Modern Medicine. 

MacCarty and Blackford. Annals of Surgery, June, 1912. 

Palmer. Surgery, Gynecology and Obstetrics, x, 154. 

Patterson. Surgery of the Stomach. 

Smithies. Collected Papers, Mayo Clinic, 1913. 

Wilson. Collected Papers, Mayo Clinic, 1913. 



CHAPTER X. 

CARCINOMA OF THE INTESTINES— SARCOMA 

OF THE INTESTINES— CARCINOMA OF THE 

APPENDIX— CANCER OF THE RECTUM. 

CARCINOMA OF THE INTESTINES. 

Etiology. — Frequency. — During the year 1912 there were 
in the registration area of the United States, 5923 deaths 
recorded from cancer of the peritoneum, intestines and 
rectum, that is, 12.7 per cent, of all deaths from cancer 
in the registration area. As cancer of the stomach and 
liver, the female generative organs, and of the other 
abdominal organs which are frequently involved in 
cancerous lesions, are included under separate headings, 
probably most of the cases of carcinoma of the peritoneum 
in this group were primary in the intestines, and therefore 
the number fairly represents the number of deaths in the 
United States registration area for a single year of cancer 
of the intestines and rectum. As the registration area for 
the year 1912 included 63.2 per cent, of the total population 
of the country, if there were proportionately the same 
number of deaths among the rest of the population, 
the total number of deaths from cancer of the intestines 
in the entire country for the year 1912 was approximately 
9372. As during the same period in the United States 
registration area there were 13,517 deaths from cancer 
of the stomach and liver, cancer of the intestines and 
rectum constitute about one-third of the cases of cancer 
of the entire gastro-intestinal tract. In Bashford's mor- 
tality statistics, in a total of 84,448 cancer deaths there 
were 5723 cases, or about 7 per cent., of the malignant 
growths of the intestine exclusive of the rectum. 



CARCINOMA OF THE INTESTINES 245 

In a series of 1453 cases of cancer of the gastro-intestinal 
tract reported by W. J. Mayo, there were 996 cases of 
carcinoma of the stomach, 16 of the small intestine, 216 
of the large intestine, and 225 of the rectum. That is, 
carcinoma of the small intestine is very rare, consisting of 
only 1.1 per cent, of all cases in the gastro-intestinal tract, 
or 3.5 per cent, of the intestinal tract; and carcinoma of 
the large intestine is more common, being found with 
approximately the same frequency as carcinoma of the 
rectum, and consisting of 15 per cent, of all gastro- 
intestinal cases. Hinz reported the combined statistics 
of 584 cases of carcinoma of the intestinal tract, of which 
18, or 3.06 per cent., were situated in the small intestine. 
Brill reported combined statistics of 2128 cases of intestinal 
carcinoma, of which 50, or 2.3 per cent., were in the small 
intestine. 

Sex. — Of the 5923 deaths recorded in the United States 
registration area from cancer of the peritoneum, intestines, 
and rectum during the year 1912, 2459, or 42 per cent., 
were in males, and 3464, or 58 per cent., were in females. 
These figures differ from those of most surgical clinics, 
as the latter record carcinoma of the intestines more 
frequent in males than in females. Hinz reports 48 cases 
of primary carcinoma of the small intestine, of which 31, 
or 65 per cent., were in males and 17, or 35 per cent., 
in females. Anschutz reports 128 cases of carcinoma 
of the large intestine, of which 91, or 70 per cent., were in 
males and 37, or 30 per cent., were in females. 

In Bashford's mortality statistics, malignant growths 
of the intestines exclusive of the rectum were more fre- 
quently the cause of death of females than of males. 
Cancer of the rectum was more common in males than in 
females. 

Considering all these statistics, it is probable that 
malignant growths of the intestinal tract occur with about 
the same frequency in the two sexes. 

Age. — Carcinoma of the intestines increases rapidly 
in frequency after the age of forty years. Of the cases 



246 CARCINOMA OF THE INTESTINES 

recorded in the United States registration area in 1912, 
90 per cent, were over forty years of age. 

Pathology. — The most frequent form of carcinoma of 
the intestines is the adenocarcinoma. It is composed of 
cylindrical cells maintaining often the type of the glands. 
The scirrhns carcinoma with a preponderance of fibrous 
tissue is the second most common variety. The colloid 
carcinoma occurs more frequently in the intestines than 
in the stomach. The growths are usually single but they 
may be multiple. 

The carcinoma may take the form of a cauliflower 
mass with a broad base, growing into the lumen of the 
intestine. Sometimes there is a growth with a small 
base or pedicle, suggesting that there has been a carcino- 
matous change in a preexisting papilloma. This type is 
sometimes seen at the biliary papilla in the second portion 
of the duodenum. Most frequently the growth is seen 
as an ulcerated area with elevated edges and a necrotic, 
broken-down centre. This ulcerated area by extension 
of the growth may suddenly perforate the bowel, causing 
a general peritonitis. More frequently the perforation 
takes place slowly, and a circumscribed abscess or a 
communication with another viscus is formed. 

The greatest tendency of the growth is to surround the 
intestine and to form a stricture, and the symptoms of 
carcinoma of the intestines are due largely to the mechani- 
cal obstruction produced by the stricture or in other ways. 
The growth, in addition to forming a stricture which 
obstructs the bowel, may grow into the lumen of the bowel 
and obstruct it by its size, or it may cause an intussuscep- 
tion, or an obstruction may be caused by a kinking of the 
bowel by its weight or by adhesions. 

Sarcoma and lymphosarcoma of the intestines occur 
less frequently than carcinoma, there being in a series of 
autopsies only 1 case of sarcoma to 40 or 50 of carcinoma. 
They differ from carcinomata in occurring with about the 
same frequency in the small and in the large intestine, 
and not tending to stricture the intestines but more to a 



CARCINOMA OF THE DUODENUM 247 

diffuse growth. This growth may be sufficient to obstruct 
the bowel, but not with the same regularity as the carcin- 
omata. The absence of obstruction makes the symptoms 
of sarcoma of the intestines different than those of 
carcinoma. 

CARCINOMA OF THE DUODENUM. 

In the series of 1453 cases of carcinoma of the gastro- 
intestinal tract reported by W. J. Mayo, 16 were in the 
small intestine, and of these only five were in the duodenum 
and none of them operable. Rolleston states that in 
18,000 autopsies at Guy's Hospital there were only 10 
cases of primary malignant disease of the duodenum, and 
of these four were carcinomata. 

The tendency of carcinoma of the duodenum, as of other 
parts of the intestine, is to form an annular stricture about 
the duodenum. The stricture may be sufficient to cause 
definite stenosis of the bowel without altering its external 
appearance. Occasionally the growth takes a polypoid 
form, especially if it starts from the mucous membrane 
in the vicinity of the entrance into the duodenum of the 
bile duct, that is, at the biliary papilla. Carcinoma 
starting at this point is sometimes erroneously confused 
with a carcinoma originating in the gall passages or in 
the ampulla of Vater. 

Symptoms. — The symptoms of a carcinoma of the 
duodenum are caused largely by two mechanical obstruc- 
tions, one to the intestine, interfering with the passage 
of the intestinal contents, the other to the common 
opening of the bile and pancreatic ducts, interfering with 
the passage of the bile and pancreatic juice into the intes- 
tines. They differ, therefore, whether the growth is 
located in the first, second, or third part of the duodenum, 
or, more accurately, whether it is located above, around, 
or below the ampulla of Vater. If the growth is above 
the ampulla of Vater, the bile and pancreatic juice pass 
as usual into the intestine. If the growth involves the 



248 CARCINOMA OF THE DUODENUM 

ampulla of Yater there may be complete or intermittent 
obstruction or infection of the bile and pancreatic ducts. 
If the growth is below the ampulla of Yater the bile and 
pancreatic fluids pass imperfectly through the intestinal 
stricture, and are to be found in the stomach contents. 

Carcinoma of the first part of the duodenum alone 
occurred, as reported by Rolleston in a series of 40 cases, 
in 8 cases, and together with the second part in 5 more. 
The symptoms closely resemble those of carcinoma of the 
pylorus of the stomach so far as the obstruction is con- 
cerned. The stomach may be dilated and contain food 
remnants. Hydrochloric acid is usually not absent. 
A tumor may be palpated in some cases. The correct 
diagnosis between carcinoma of the first part of the duo- 
denum and the pyloric orifice of the stomach is rarely 
made except at operation or autopsy. The absence of 
bile and pancreatic juice in the contents of the stomach is a 
characteristic sign which may help to distinguish it from 
carcinoma lower in the duodenum. 

Carcinoma of the second part of the duodenum, if situated 
above the ampulla of Yater, gives the same symptoms 
as if situated in the first part; if situated below the ampulla 
of Yater, it gives the symptoms as if situated in the third 
part; if situated about the ampulla of Yater, it gives symp- 
toms of intestinal obstruction and symptoms of obstruction 
and possibly inflammation of the biliary passages. In the 
series of 40 cases of carcinoma of the duodenum reported 
by Rolleston, 24 were limited entirely to the second 
portion and 5 others involved both the first and second 
parts; that is, the second part of the duodenum, particu- 
larly around the biliary papilla, is the most common 
location of a carcinoma of the duodenum. 

The involvement of the biliary papilla by a carcinoma 
of the duodenum causes jaundice, enlargement of the gall- 
bladder, clay-colored movements and high-colored urine 
by the obstruction of the outflow of bile into the intestine. 
By ulceration of the growth, this obstruction may be 
relieved and the symptoms temporarily subside. In car- 



TREATMENT 249 

cinoma of the gall passages, if the ampulla of Vater and 
of the head of the pancreas are involved, these symptoms 
are progressive and continuous and not intermittent, as 
they frequently are in carcinoma of the second portion of 
the duodenum. 

With the extension of the growth, there is a catarrhal 
duodenitis and an inflammatory involvement of the bile 
passages, giving tenderness and enlargement of the liver 
and increase in the temperature and pulse, that is, the 
signs of acute infection. A suppurative inflammation of 
these ducts may be the cause of death. 

Carcinoma of the third part of the duodenum occurred in 
only 3 of the 40 cases reported by Rolleston and is there- 
fore the least frequent location of cancer of the duodenum. 
The symptoms are those of intestinal obstruction which 
progresses as the stenosis increases. In the early stages 
of the disease, bile and pancreatic fluid would be mixed 
with the intestinal contents which pass the stricture, so 
the color of the movements may not be changed. Later 
the movements will be light or clay-colored. As the 
growth is below the ampulla of Vater, both bile and 
pancreatic fluid may be found in the stomach contents. 

Prognosis. — The prognosis of carcinoma of the duodenum 
is unfavorable largely on account of the difficulty of the 
diagnosis. Of the 5 cases of carcinoma of the duodenum 
and 2 of the duodenojejunal angle reported by Maj^o, 
all were inoperable. 

Treatment. — The only treatment of carcinoma of the 
duodenum which offers any possibility of permanent 
relief to the patient is the surgical excision of the growth, 
and this is possible only in the early stages of the disease. 
The location and the anatomical relations of the duodenum 
make the removal of a growth more difficult than from 
any other part of the intestine. If removal is not possible, 
a gastrojejunostomy may be indicated to relieve the 
symptoms of obstruction. 



250 CARCINOMA OF THE JEJUNUM AND ILEUM 



CARCINOMA OF THE JEJUNUM AND ILEUM. 

Carcinoma of the jejunum and ileum are very rare, 
though they constitute a large part of the total length of 
the intestinal tract. There are various causes suggested 
for the rarity of carcinoma of the small intestine compared 
with the large intestine. Probably the fluid condition 
of the intestinal contents and the absence of angles for 
resistance to its progress are the most important factors. 
By analogy intestinal ulcers, as from typhoid fever or 
dysentery or their scars, would influence the development 
of a carcinoma but the recorded cases are too few to prove 
the assumption. 

Symptoms. — If there is no stricture, there are no local 
signs and the symptoms are those of carcinoma in general. 
If there is a stricture, in addition to the general symptoms 
of carcinoma, there are the local symptoms due to the 
intestinal obstruction. As the intestinal contents are 
fluid, the signs of obstruction do not develop as early in 
the course of the disease as in the large intestine. The 
bowels may be constipated or alternating with diarrhea. 
A tumor may be present but it is not easy to distinguish 
it from one in the large intestine. There may be blood in 
the movements. The Roentgen-ray picture may be of con- 
siderable assistance in locating the stricture particularly 
if repeated examinations are made. 

Prognosis. — As local symptoms usually develop late, few 
cases are seen early enough to be relieved by a radical 
operation. Of 44 cases of carcinoma of the small intestine 
reported by Hinz, 12 cases had no operation at all, 4 
cases only an exploratory celiotomy, 12 cases a palliative 
operation and 16 cases a radical operation. Of the 16 
cases subjected to a radical resection, 7 cases died from 
the operation, 3 died of recurrence and 2 of intercurrent 
disease without metastases within two years. One was 
free of recurrence at the end of seven years and two at the 
end of three years. 

Hinz divides the cases in his series into two groups: 



CARCINOMA OF THE LARGE INTESTINE 251 

those with stenosis and those without stenosis. There 
were 28 cases with intestinal stenosis, of which 12 cases, or 
43 per cent., were subjected to a radical operation. There 
were 16 cases without intestinal stenosis, of which 4 
cases, or 25 per cent., were suitable for radical removal. 
The study of these two groups would indicate that the 
cases with intestinal stenosis come earlier to operative 
treatment. This is probably due to earlier local signs. 
The late stage at which the cases come to operation 
probably explains the high operative mortality and the 
poor end results. The nature of the operation is not 
one that should be associated with a great risk, and the 
anatomical relations of the intestine and the nature of 
the growth, favor better end results. A number of the 
cases included in the series were operated upon previous 
to the more modern intestinal technique. This of course 
greatly influences the results. 

Treatment. — The surgical treatment may be radical or 
palliative. The radical operation consists of the removal 
of the growth with the neighboring lymphatic glands and 
joining the intestine either by a lateral or an end-to-end 
anastomosis. The palliative operation consists of making 
an anastomosis between two coils of the intestine, leaving 
the carcinoma out of the course of the intestinal contents. 

The medical treatment is to relieve pain with codeine, 
and when necessary with morphine, to assist the bowels 
to overcome the obstruction in the intestine, and to treat 
other symptoms that may arise. 

CARCINOMA OF THE LARGE INTESTINE. 

Etiology. — Frequency. — In the series of 1453 cases of 
carcinoma of the gastro-intestinal tract reported by Mayo, 
215, or about 15 per cent., occurred in the large intestine. 
That is, carcinoma is much more frequent in the large than 
in the small intestine, and occurs with about the same 
frequency in the entire large intestine, including the 
sigmoid flexure, as it does in the rectum. 



252 CARCINOMA OF THE LARGE INTESTINE 

Sex. — Of 128 cases of carcinoma of the large intestine 
reported by Anschutz from the Breslau surgical clinics, 
there were 91 males and 37 females. Of 39 cases reported 
by Denk from von Eiselberg's clinic, 23 were males and 
16 females. Other observers report a smaller difference 
in the liability of the sexes to the disease, but all seem to 
indicate that the condition is more common in males than 
in females. This agrees with the occurrence of carcinoma 
in other parts of the gastro-intestinal tract, as reported 
from various surgical clinics. 

As stated elsewhere, Bashford's mortality statistics 
give malignant growths of the intestines as a more frequent 
cause of deaths of females than of males. As cancer of the 
rectum is grouped separately and the small intestine is 
rarely the seat of a primary malignant growth, his statistics 
are practically those of the large intestine alone. 

Age. — Carcinoma of the large intestine follows the usual 
rule as to age. Most cases occur after the age of forty 
years, but it is occasionally observed in early years. Of 
the 128 cases reported by Anschutz, there were 2 cases 
between the ages of ten and twenty years, 6 cases between 
twenty and thirty years, 20 cases between thirty and forty 
years, and 100 cases over forty years. In Denk's series 
there were 2 cases between the ages of twenty and thirty 
years, 2 cases between thirty and forty years, and 35 
cases past forty years. 

Location. — In the 128 cases reported by Anschutz and 
the 39 cases reported by Denk the location of the growth 
was as follows: 

Anschutz's series. Denk's series. 

Cecum 24 11 

Ascending colon 10 4 

Hepatic flexure 9 3 

Transverse colon ..... 15 4 

Splenic flexure 17 4 

Descending colon 4 1 

Sigmoid flexure 49 12 

128 39 



ETIOLOGY 253 

The frequency with which the different parts of the 
large intestine are involved is nearly in the same proportion 
as each of these series, and follows in the order of the 
theoretical amount of irritation from the intestinal con- 
tents. In the sigmoid flexure, the fecal matter is not only 
more solid than in the other parts of the large intestine, 
but it may be actually hard and irritating and it may be 
retained there for a considerable period of time, much 
longer than at any other place. At this point there is the 
greatest amount of irritation to the lining of the intestine 
from the intestinal contents, and it is also here that the 
greatest number of cases of carcinoma of the large intestine 
is found. In contrast to the sigmoid flexure, carcinoma of 
the large intestine is least frequent in the descending colon, 
a part which offers little resistance to the onward passage 
of the intestinal contents and which much of the time is 
entirely empty. Next to the sigmoid flexure the cecum is 
the most frequent site in the large intestine for a carcinoma 
to develop, and it is also a place in which feces are often 
abnormally retained. Comparing the hepatic and splenic 
flexures, it is found that carcinoma is more frequent in the 
latter than in the former locality. The more solid condi- 
tion of the feces and the more acute angle of the splenic 
flexure would explain the difference. 

Moynihan doubts the accuracy of the belief that car- 
cinoma of the colon is more frequent at the flexures and 
believes that it rarely occurs at the exact bend of the 
bowel, but one, two or three inches from it. He states that 
he has never seen a growth develop exactly at the hepatic 
flexure and rarely at the splenic flexure. 

Trauma. — It is difficult to trace the direct connection 
between an external injury and a carcinoma of the large 
intestine. ' The large intestine is well protected in the 
abdomen and it is not easily injured. The cases reported 
as occurring as the result of injury are probably cases 
in which there was a preexisting cancer and the injury 
started or directed attention to the symptoms. 



254 CARCINOMA OF THE LARGE INTESTINE 

Constipation. — Internal injur}* to the mucous membrane 
by hard or irritating feces is a more likely cause of the 
malignant growth. It has already been stated that 
carcinoma develops most frequently in those parts of the 
intestine which are subjected to the greatest irritation. 

Ulcers. — It has not been demonstrated that carcinoma 
develops in an intestinal ulcer as it has that it develops 
in a gastric ulcer. Intestinal ulcers are not as frequent 
as gastric ulcers, and would not as often be the cause of 
the development of a cancer. By analogy to the condi- 
tions in the stomach, and by our knowledge that cancer 
results from continued irritation, particularly of an abnor- 
mal lesion, it is probable that an intestinal ulceration or 
scar may predispose to the formation of a carcinoma of 
the intestine. 

Polypoid Growths. — These are in the same category as 
intestinal ulcers. Even if originally benign, the constant 
irritation of the feces may favor the change to a malignant 
growth in the large intestine, as is more frequently demon- 
strable in the rectum. 

Symptoms. — Pain. — This is usually but not invariably 
present in intestinal carcinoma. It may be an indefinite 
discomfort over the entire abdomen and become localized 
only during the late stages. When it is localized it is 
usually over the growth, but may be in another part of 
the abdomen. The most characteristic type of pain is 
the attacks of colic due to the tonic peristaltic action of the 
bowels above the stricture. This may be started by an 
attack of indigestion, traumatism or anything causing 
irritation of the intestine. 

Constipation. — This is one of the early and most constant 
symptoms of intestinal carcinoma. It is progressive and 
gradually becomes more marked as the disease advances. 
It may be relieved by attacks of diarrhea during which 
the intestinal contents, being more fluid, pass through the 
stricture. It may also be relieved by sloughing of the 
growth, if the lumen of the intestine is made more 
patent. 



SYMPTOMS 255 

Flatulence. — On account of the retention of the intestinal 
contents, there is an increased production and a diminished 
expulsion of gas which causes intestinal distention. This 
may be extensive and cause a general abdominal disten- 
tion. More frequently it is limited or most marked in 
the intestine directly above the growth. 

Obstruction. — An absolute intestinal obstruction may be 
the first symptom of a carcinoma of the large intestine. 
The obstruction may be caused by a volvulus or an 
intussusception or a kinking of the intestine. Of 128 
cases in the series reported by Anschiitz, there were 51 
cases, or 40 per cent., of ileus, and of these 50 per cent, 
died. The following table taken from his article gives 
the location, the number of cases of ileus, and of deaths : 

Cases. Ileus. Deaths. 

Cecum 24 

Ascending colon .... 10 

Hepatic flexure 9 

Transverse colon .... 15 

Splenic flexure 17 

Descending colon .... 4 

Sigmoid flexure .... 49 

128 51 25 

Tumor. — The demonstration of a tumor attached to 
the colon is a sign of most importance in the diagnosis 
of carcinoma of the large intestine. A tumor was present 
in 66, or approximately one-half of the 128 cases in 
Anschutz's series. The tumor mass may be composed 
partly of the malignant growth and partly of fecal matter. 
Tlir size of the tumor varies on different days and is 
diminished if the bowels are thoroughly emptied by 
laxatives and the fecal obstruction removed. At times 
the tumor, which may be felt on some days, entirely 
disappears <>n others. The tumor is usually sensitive to 
pressure. 

Increased Peristalsis. — This is a natural symptom to 
expect with the intestinal stenosis. There is an obstruc- 



6 


4 








4 


3 


1 


1 


9 


6 








31 


11 



256 CARCINOMA OF THE LARGE INTESTINE 

tion to the passage of the fecal matter through the 
stricture; the intestine must use more force to get it 
through. This increased peristalsis may be seen in 
waves or felt with the hand on the abdomen. The 
increased peristalsis was noticed in about 43 per cent, 
of the cases in Anschiitz's series. Associated with the 
increased peristalsis are attacks of colicky pain. These 
attacks may be relieved by attention to diet and the 
regulation of the bowels. 

Feces. — There is little to be learned from the shape 
of the movements. They may be small in size or ribbon- 
shaped if the growth is in the rectum but not if it is above 
the sigmoid. 

The microscopic examination of the feces may give more 
and definite information. Blood, pus, mucus, and pieces of 
tissue may be found. The blood may be either visible 
or occult. Care must be taken to exclude gastric, intestinal, 
and rectal ulcers, hemorrhoids, -fissure, etc. If the pres- 
ence of the blood is persistent, particularly if associated 
with pus and mucus, carcinoma of some part of the 
gastro-intestinal tract should be suspected. Pus is of more 
significance than mucus, as the latter is often the result 
of a catarrhal inflammation of the intestine. Pieces of 
tissue may be found and are of positive diagnostic value. 
If the growth is in the sigmoid there may be tenesmus. 

Perforation.— This may be the result of the necrosis of a 
portion of the intestine strangulated by the ileus, or it 
may be the result of the extension of the growth itself. 
If the perforation is rapid, as in cases associated with 
ileus, a general septic peritonitis is the immediate result. 
If it occurs more slowly, adhesions between the intestine 
and surrounding organs will have formed and a circum- 
scribed abscess, or a fistula between the intestine and some 
other organ, most frequently the stomach and bladder, 
or a general peritoneal carcinosis will result. If the com- 
munication is formed with the stomach, fecal matter will 
be found in gastric contents or undigested pieces of food 
with the movements. If with the bladder, fecal matter 



TREATMENT 257 

will be passed with the urine. Such conditions will occur 
only in the late stages of the disease. 

Metastases. — It is generally accepted that metastases 
from a carcinoma of the large intestine occur late. This is 
a factor in the favorable results obtained by operation 
on those cases seen in the stage in which a radical operation 
is possible. It is another indication of the mild degree of 
malignancy shown by most cases of carcinoma of the large 
intestine. Metastases occur most frequently in the liver 
and in the mesenteric lymph nodes. The involvement of 
the peritoneum is frequent and results from direct exten- 
sion and peritoneal transplantation of cancer cells. 

Prognosis. — Carcinoma in the large intestine shows a 
milder degree of malignancy than in any other organ, 
though without operation all cases are ultimately fatal. 
Without operation the average course of carcinoma of the 
large intestine is from two to four years. As there are 
no symptoms in most cases in the early stages, it often is 
impossible to determine the approximate duration but 
probably some of the most malignant cases terminate 
fatally in six months. There are a number of cases that 
have had an exploratory celiotomy, and concerning the 
diagnosis of which there can be little doubt, that have 
lasted over three years. The cases that are said to have 
lasted five or six or more years are questionable. The 
probable explanation of these cases is that a malignant 
process has developed in a preexisting benign tumor or 
stricture. It is not likely that a carcinoma of even a 
mild degree of malignancy could last so long a time. 

Treatment. — For the consideration of the treatment, 
the cases of carcinoma of the large intestine will be divided 
into two classes, depending on the presence or the absence 
of complete intestinal obstruction. 

In carcinoma of the large intestine with complete 
obstruction, the immediate indication is to relieve the acute 
condition. This indication is to form an artificial anus 
or ;in intestinal anastomosis, but with rare exceptions not 
to attempt to remove the growth. The general condition 
17 



258 CARCINOMA OF THE LARGE INTESTINE 

of the patient and the local disturbance in the peritoneum 
are unfavorable to any extensive operative work. Many 
of these cases have had previous attacks of obstruction 
which have been relieved by medical means. 

It may be difficult to determine when the attack requires 
surgical interference. By waiting, if the obstruction is 
relieved by medical means, any operation will be avoided 
or done under more favorable conditions, and a single 
operation instead of two may be sufficient. By waiting 
too long, strangulation and perforation of the intestine 
may result, and a general peritonitis develop. The safer 
plan is to interfere surgically too early rather than too late. 

1. The artificial amis should be made at the most con- 
venient place above the obstruction. If it is made too 
near the obstruction, the extension of the growth may 
interfere with its function and necessitate a subsequent 
operation. If it is made at too great a distance from the 
obstruction, there may be retention of discharge in the 
intervening portion of the intestine which may cause 
trouble. The operation is a simple one and can be done 
under local anesthesia if necessary. The deaths following 
it are usually due to the condition requiring it and not to 
the operation itself. The most frequent cause of death is 
general peritonitis, which had started previous to the 
operation, or which may develop subsequently from 
perforation of the intestine at the site of the growth or at 
the point of strangulation. If the condition of the patient 
will permit, it is best to do the operation in two stages, 
first suturing the intestine to the abdominal wall, and 
opening it a few hours later when the intestine has become 
adherent to the peritoneum. 

2. An intestinal anastomosis for an obstruction due 
to a malignant growth is a more ideal operation than an 
artificial anus, but is associated with a greater risk and 
is justifiable in few cases. It requires the anastomosis 
of the intestine above the obstruction, which is distended, 
to that below the obstruction, which is collapsed. This is 
technicallv difficult and associated with an increased risk. 



TREATMENT 259 

The technical difficulties, the local and general condition 
of the patient, and the increased time of the operation 
are all against the intestinal anastomosis and in favor of 
the artificial anus. An intestinal anastomosis in prefer- 
ence to an artificial anus should never be done excepting 
under favorable conditions. If the case is seen early, 
when the general condition of the patient is good, when 
there is no peritoneal disturbance, and only moderate 
distention of the intestine above the obstruction, an anas- 
tomosis may be indicated. These conditions, unfor- 
tunately, do not often obtain. 

The location of the growth is a factor in deciding 
between an anastomosis and an artificial anus. If the 
growth is situated in the sigmoid flexure and cannot be 
removed, an artificial anus in the colon is the only relief 
that can be given to the patient. An artificial anus in the 
colon does not interfere with the nutrition of the patient, 
and is relatively easy to care for. If, however, the growth 
is in the cecum, the artificial anus would have to be in the 
small intestine. The more fluid condition of the intestinal 
contents in the small intestine makes such an anus more 
difficult to care for and more disagreeable to the patient. 
This fact, together with the possible interference w T ith 
nutrition, would make a subsequent anastomosis desirable 
even if the growth could not be radically removed. 

That is, the advantage to be gained by the immediate 
anastomosis is obtained only when the growth is situated 
in the upper part of the colon. It is a mistake to seek 
the advantage at too great risk to the patient, and the 
cases of obstruction due to an intestinal carcinoma in 
which an immediate anastomosis is indicated are 
infrequent. 

:;. The radical removal of a carcinoma of the large 
intestine during an obstruction is the ideal operation but it 
is tint frequently possible. The resection of the intestine, 
thai is, the removal of the growth and anastomosis of 
divided intestine, is technically difficult for the reasons 
already given. It is associated with a mortality estimated 



260 'CARCINOMA OF THE LARGE INTESTINE 

between 50 per cent, and 70 per cent, and is therefore 
rarely indicated. There are some cases in which the 
growth is situated in a loop of intestine with a long 
mesentery, or which can easily be mobilized, that can be 
treated by drawing the intestinal loop containing the 
growth outside of the abdomen and fastening it to the 
abdominal wound. The growth is removed at once 
or after adhesions have formed, as the case indicates, 
leaving an artificial anus. In these cases, before the abdo- 
men is closed, the portion of intestine leading to the 
growth and that leading from it are brought together 
laterally forming a spur in the artificial anus. This spur 
is later divided by the application of a clamp and the 
anus closed. The objection is raised to this method 
that it is applicable only to cases favorable to a radical 
operation, and in such cases if an artificial anus is first 
made and the removal of the growth left for a subsequent 
operation under more favorable circumstances, a more 
radical operation with greater attention to the removal 
of lymphatic glands can be performed, giving a greater 
chance for a permanent cure. 

For carcinoma of the large intestine without acute 
obstruction there are also three operative procedures. 
They are: 

1 . Radical removal. 

2. Intestinal anastomosis without removal. 

3. Artificial anus without removal. 

1. The radical removal of a carcinoma of the large intes- 
tine is the only operation that will cure the patient and 
all other operations are merely to relieve symptoms. In 
properly selected cases, the operative mortality is becom- 
ing constantly lower and the end results more favorable. 
With carcinoma of the large intestine as in other organs, 
a lower operative mortality and a higher percentage of 
permanent cures are to be obtained by earlier diagnoses. 
The operative risk of the removal of an early growth in 
the large intestine is no greater than of the removal of 
malignant growths from other abdominal organs and on 



TREATMENT 261 

account of late metastases and the nature of the growth 
itself, the end results are probably more favorable than 
those following the removal of malignant growths from 
any other organ. 

The radical removal of a carcinoma of the large intestine 
may be accomplished in a one-stage or a two-stage opera- 
tion. The one-stage operation is usually performed for 
all malignant growths in the first half of the colon or as 
far as the splenic flexure, because the movable ileum can 
easily be anastomosed to the transverse colon and for 
favorable cases beyond the splenic flexure. For a growth 
in the lower half of the colon, particularly in the sigmoid 
flexure, and in advanced cases, the two-stage operation 
is more often selected, as an anastomosis between two 
parts of the large intestine is more difficult. 

The one-stage operation is the ideal operation but it is asso- 
ciated with a higher primary mortality. In it the growth 
is removed and the intestine immediately reunited either by 
an end-to-end or a lateral anastomosis. A liberal portion 
of apparently health}' intestine is removed on each side 
of the growth to be sure that all malignant tissue in the 
intestine is removed. Metastases appear late, but all 
lymphatic glands along the course of the vessels should be 
removed. If the growth is in the cecum, about four inches 
of the ileum, the cecum, appendix, ascending colon, 
hepatic flexure, and a part of the transverse colon are 
removed and the ileum anastomosed to the transverse 
colon, that is, an ileocolostomy is made. The amount 
of colon removed is partly to extirpate the disease widely 
and partly to permit the more easy anastomosis between 
the ileum and the transverse colon. The same operation 
is done if the growth involves the ascending colon or 
hepatic flexure, except that a larger portion of the trans- 
verse colon is removed. It' the growth is in the transverse 
colon it may be removed and the colon directly reunited 
either by end-to-end or the lateral method. The trans- 
verse colon is usually sufficiently looped downward to 
allow easy access to it and room for the direct anastomosis 



262 CARCINOMA OF THE LARGE INTESTINE 

after the growth has been removed. Carcinoma of the 
splenic flexure and of the descending colon may also be 
treated by removal and immediate anastomosis. After 
a removal of a carcinoma of the sigmoid flexure the ends 
of the intestine should be anastomosed if possible. In 
some cases this is not possible and a permanent colostomy 
may be necessary. 

In the two-stage operation the loop of colon containing 
the carcinoma is "mobilized," that is, it is freed of its 
peritoneal attachments, until the growth with a liberal 
amount, that is, three or four inches, of normal intestine 
on either side of it can be withdrawn and fastened outside 
of the abdominal wall. Before closing the abdomen the 
two pieces of intestine, the one leading to the growth and 
the one leading from it, are sutured together laterally. 
After adhesions between the intestinal loop and the 
parietal peritoneum have formed, the growth is cut away. 
By this procedure the danger of peritoneal infection from 
intestinal contents is avoided. Later, usually at the end 
of about three weeks, the spur is removed by the applica- 
tion of a clamp and the artificial anus is closed. 

2. An intestinal anastomosis without removal for 
carcinoma of the large intestine is, of course, not curative, 
and is made to relieve pain or chronic obstruction in cases 
otherwise inoperable. It has obvious advantages over an 
artificial anus, though associated with a slightly increased 
operative risk. The simplest method is to anastomose 
laterally the intestine above the growth to some portion 
below it. The intestinal contents are thus side-tracked 
around the stricture, and the obstruction and pain are 
relieved. When anastomosed in this way, there is a 
tendency for the intestinal contents to pass along the colon 
in the normal track instead of passing through the new 
opening, and to keep up the pain and irritation of the 
growth. To avoid this in some cases, the loop of intestine 
containing the growth is entirely severed at the proximal 
or oral side so that none of the intestinal contents pass 
into the loop containing the growth but are side-tracked 



OPERATIVE MORTALITY 263 

around it by means of an end-to-side or lateral anastomosis. 
The treatment of the loop which has been excluded is 
varied. Formerly the ends were turned in, sutured, and 
returned to the abdomen without drainage. By this 
method, there was no outlet for the intestinal secretions 
and discharges from the growth, and trouble resulted. 
It is therefore necessary to drain this excluded intestinal 
loop. This is usually done by forming an external 
fistula sometimes by an anastomosis to the sigmoid flexure. 

3. An artificial anus is rarely made for a growth in the 
intestine in the absence of an acute obstruction. There 
are some inoperable cases, situated too low in the colon 
or sigmoid to permit an anastomosis, in which an artificial 
anus is necessary to relieve the chronic obstruction and 
pain. If the growth is higher in the colon, even if other- 
wise inoperable, an anastomosis around it is possible 
and a more satisfactory result obtained. 

Operative Mortality. — This is not easy to state in 
definite figures for as much depends on the condition of 
the patient and on the local condition as the operation. 
The cases with ileus should be separated from those 
without symptoms of acute obstruction. 

With an acute obstruction an intestinal resection is 
associated with a mortality estimated as high as 75 per 
cent, and on account of the high risk is rarely done. This 
mortality rate is considerably lessened, even during ileus, 
by the two-stage operation in which the growth is drawn 
outside of the abdomen and an artificial anus made. 
The formation of an artificial anus is associated with the 
least risk of all the operative procedure for the relief of an 
obstruction due to a carcinoma of the intestine. 

Without an acute obstruction the danger of an intestinal 
resection is distinctly less and depends on the extent and 
location of the malignant growth. 

Anschiitz, in a series of cases of primary intestinal 
resection tor carcinoma of the large intestine, collected 
from various authors and from which all cases of ileus 
were excluded, reported an operative mortality of 46 



264 SARCOMA OF THE INTESTINES 

per cent. This percentage is, however, misleading, as 
many of these cases were operated upon previous to the 
development of modern intestinal surgery. Mayo, in 
1909, reported eight deaths or 13 per cent, in 61 cases of 
resection for carcinoma of the large intestine. The low 
rate for primary resection of the colon for carcinoma can 
only be obtained by doing a resection on cases suitable 
for it. The two-stage operation for a certain class of 
cases has lowered the mortality from primary resections. 
Anschiitz in the same article in which he reported a 
mortality rate of 46 per cent, for prima^ resection, 
reported only 12.5 per cent, operative mortality for the 
two-stage operation. The two-stage operation has been a 
distinct advance in the surgery of the large intestine. 

End Results. — An artificial anus and an intestinal 
anastomosis around the growth are only palliative opera- 
tions and ultimately the disease terminates fatally. 
The palliative operation has not only relieved symptoms 
but doubtless prolonged life. The average duration of 
life after the formation of an artificial anus, according to 
Anschiitz, is approximately one and a half years. This 
is a very favorable result when it is remembered that these 
operations are performed only on cases otherwise inoperable. 

The end results of the radical operation for carcinoma 
of the large intestine are very favorable. If only cases 
that are operated upon according to modern ideas of the 
surgery of the large intestine are considered, and cases 
previous to ten years ago are excluded, probably 50 per 
cent, of the cases that recover from the operation are free 
of recurrence at the end of five years. The results of the 
removal of malignant growths of the large intestine by 
modern methods are probably more favorable than the 
removal of such growths from any other abdominal organ. 

SARCOMA OF THE INTESTINES. 

Etiology. — Frequency.— Sarcoma of the intestines is a 
rare disease. Only 1 or 2 per cent, of the cases of malig- 



PATHOLOGY 



265 



nant disease of the intestines are sarcomata. Unlike 
carcinoma, sarcoma occurs with the same or greater 
frequency in the small than in the large intestine, and in 
the small intestine it occurs with nearly equal frequency 
in each of the three parts. 

Sex. — Sarcoma of the intestines occurs somewhat more 
frequently in males than in females. In a series of 22 
cases of sarcoma of the large intestine reported by Jopson 
and White there were 12 males and 10 females. In 101 
cases, Speese reports 67 cases were in males and 34 in 
females. 

Age. — The following table gives the age of a series of 
51 cases of sarcoma of the small intestine collected by 
Libman and of a series of 22 cases of sarcoma of the large 
intestine collected by Jopson and White: 





Small 


Large 




Age. 


intestine. 


intestine. 


Total. 


Under 10 years . 


. 6 


7 


13 


10 to 20 " . . 


. 9 


3 


12 


20 to 30 " . . 


. 13 


4 


17 


30 to 40 " . . 


. 13 


5 


18 


40 to 50 " . . 


. 8 


1 


9 


50 to 60 " . . 


1 


1 


2 


Over 60 " . . 


1 


1 


2 



51 



22 



73 



The early age, especially when compared with carcinoma 
of the intestine, is noticeable. Of the total number of 
cases in the two series, 18 per cent were under ten years of 
age and 70 per cent, were under thirty years of age. 
One case of sarcoma of the small intestine was congenital. 

Pathology. — Sarcoma of the intestine may begin in the 
lymphoid tissue in the intestinal wall or in the connective 
tissue. The lymphosarcoma and the small round-cell 
variety are the most common types and constituted 77 
cases in a series of 99 cases. The growth is usually single, 
and involves only a limited portion of the intestine, but 
it may be multiple or it may involve a large part of the 
intestinal tract. The tendency of the growth is to spread 
in the submucus and muscular coats, but later may 



266 SARCOMA OF THE INTESTINES 

penetrate the serous layer and involve neighboring coils 
of intestine by direct extension. On account of the 
weakening of these coats, possibly also by interference with 
the nerve supply, there is a distention of the intestine. 
The distention may involve a part of the circumference 
of the intestine giving rise to a globular swelling on one 
side, or more rarely it may involve the entire circumference 
of the intestine producing a fusiform swelling. In a few 
instances the sarcoma has been found to grow toward the 
lumen of the intestine, producing an obstruction by the 
size of the tumor but not usually by the formation of a 
stricture as is frequent with carcinoma of the intestine. 
In a few cases in which fibrous tissue predominated, a 
true stricture has been found. The tendency of sarcoma 
of the intestine, especially of lymphosarcoma and of 
round-cell sarcoma, is to spread to the neighboring lymph 
glands in the mesentery. These metastases are formed 
early in the disease. Later the abdominal organs, particu- 
larly the liver, are involved with metastatic deposits. 

The tendency of a sarcoma of the intestine to produce 
a distention of the bowel is characteristically different 
than carcinoma which tends to cause a stricture, and is 
the cause of marked difference in the symptoms of the 
two diseases. In carcinoma of the intestine, the first 
symptoms are those due to the increasing obstruction to 
the intestinal contents. In sarcoma there is usually 
distention instead of stricture of the intestine and there 
are no early local symptoms as in carcinoma. 

Symptoms. — General. — In sarcoma of the intestine, 
the early symptoms are the constitutional symptoms of a 
malignant growth without the local signs. The patient 
becomes anemic and there is marked loss of flesh and 
strength. There may be nausea and vomiting and a 
general disturbance in the gastro-intestinal tract without 
definite local symptoms. 

Pain. — This is not an early symptom of the disease. 
There is more general abdominal discomfort than actual 
pain. Later the abdomen may be distinctly tender. 



PROGNOSIS 267 

Bowels. — Constipation may result from lessened nerve 
and muscle power or more rarely by the extension of the 
tumor toward the lumen of the intestine or by the forma- 
tion of a true stricture. Constipation as a symptom of 
intestinal sarcoma is mentioned more frequently in cases 
recently reported than formerly. Complete obstruction 
from kinking or intussusception has been reported in a 
number of cases. 

Abdominal Distention. — In addition to the enlargement 
of the bowel at the site of the tumor, there may be a 
general abdominal distention due to the constipation and 
accumulation of gas, or to the peritoneal involvement or 
to the pressure on vessels by extension of the growth. 
The abdominal distention may come on suddenly and 
resemble tuberculous peritonitis. 

Tumor. — Late in the course of the disease, a tumor 
may be palpated. The tumor is usually not tender and 
moderately movable. If limited to a single coil of 
intestine, it may feel smooth, soft, and cystic. If other 
coils of intestine are involved by extension, it is a more 
hard, irregular, indefinite and less movable mass. 

Feces. — Blood, either visible or occult, may be found 
in the feces, especially if the growth is in the large intestine. 
Sloughing of the growth does not occur as regularly as 
it does with carcinoma but it may happen and the feces 
may contain pus and pieces of tissue. 

In a case reported by Bjorkenheim, a sarcoma of the 
intestine was diagnosed as an ovarian cyst. This mistake 
has been noted by other observers. As the sarcoma 
frequently occurs in the small intestine which is movable, 
it gravitates to the pelvis. A tumor in that locality with 
a cystic feeling in a female would easily be diagnosed as an 
ovarian cyst. 

Prognosis.— This is always bad and there are tew cases 
on record of a sarcoma of the intestine being cured even 
by surgical interference. The absence of early local symp- 
toms prevents a diagnosis and an operation, at a stage of 
the disease during which a permanent cure would be 



268 CARCINOMA OF THE APPENDIX 

likely. Most cases die within the first year and rarely 
does a case last over eighteen months after the appearance 
of the first symptoms. 

Treatment. — The surgical removal of the growth offers 
the only hope of a permanent cure and should be done 
when possible. A case of sarcoma of the intestine is 
rarely diagnosed previous to operation, and most cases 
on which an operation has been performed were incorrectly 
diagnosed or discovered only by an exploratory celiotomy. 
If by direct inspection, it seems probable that the growth 
can be removed, a resection would be indicated. As 
many of these cases are in the small intestine, and symp- 
toms of obstruction are not usually present, neither an 
artificial anus, nor an intestinal anastomosis without 
removal of the growth, would often be indicated, as in 
carcinoma of the intestine. Medical treatment would be 
directed to alleviating symptoms. 



CARCINOMA OF THE APPENDIX. 

Etiology. — Frequency. — In a total of 8039 specimens 
from the Mayo Clinic, MacCarty and McGrath reported 
40 cases, or 5 per cent., of carcinoma of the appendix. 
In 5 cases only w^ere there gross changes which suggested 
carcinoma. In the remaining 35 cases the carcinoma 
was discovered at the routine examination in the patho- 
logical laboratory. In a total of 6505 appendices from a 
number of operators there were, as reported by 
McWilliams, 26 cancer, or about 0.4 per cent. In this 
series, however, probably all the appendices removed 
were not examined, and doubtless more cases would have 
been found if a routine examination of all specimens 
removed had been made. 

In a number of instances a carcinoma w r as found in an 
appendix which was removed at an operation for some 
pelvic lesion with no suspicion that the appendix itself 
was diseased. This is in favor of removing the appendix, 



ETIOLOGY 269 

if it is easily accessible and the patient is in good con- 
dition, during operations for other abdominal lesions. 

Age.— In the series of MacCarty and McGrath one 
case, a female, occurred at five years and two cases, one a 
male, the other a female, at ten years of age. The average 
age of all the cases was thirty years. It is of interest 
that the child of five years with the carcinoma of the appen- 
dix had had symptoms since her birth. 

In the series reported by McWilliams and that of Rolles- 
ton, a total of 78 cases, there were 2 cases under ten 
years of age and 16 between the ages of ten and twenty 
years. The average age of these 78 cases was 27.7 years. 
McWilliams has called attention to the early average age 
of cases of carcinoma of the appendix, compared with that 
of other parts of the intestinal tract, and that the age of 
cancer of the appendix coincides with that of appendicitis. 
This is of value in considering the influences of chronic 
inflammation of the appendix as a cause for the develop- 
ment of carcinoma of the appendix. 

Sex. — Of 37 cases in the series of MacCarty and 
McGrath with complete records, there were 26, or 70 
per cent., females and 11, or 30 per cent., males. In the 
combined statistics of McWilliams and Rolleston there 
were 44, or 57 per cent., females and 33, or 43 per cent., 
males. In all other parts of the gastro-intestinal tract, 
carcinoma is probably more frequent in males than in 
females. A possible explanation of the greater number 
of cases of carcinoma of the appendix in females is the 
greater number of abdominal operations performed in 
women and the removal of the appendix even though it 
is not apparently diseased. Chronic appendicitis may 
be more common in men, but more women have their 
appendices removed, and possibly for this reason more 
cases of carcinoma are found. 

Concretions. — In the scries of 90 cases reported by 
McWilliams there were only 5 cases in which a concretion 
and one other case in which a fish-bone was found. Con- 
cretions were found less frequently than in chronic 



270 CARCINOMA OF THE APPENDIX 

appendicitis. This is in contrast to carcinoma of the gall- 
bladder which is frequently associated with gall-stones and 
which are believed to favor the development of carcinoma 
in that organ. A possible explanation is the difference of 
real irritation in the two conditions. Gall-stones are 
hard and the gall-bladder is frequently changing in size 
so that there is definite irritation to its lining. It is the 
constant, frequently repeated irritation that is a factor 
in the development of a carcinoma. The concretion in an 
appendix in reality is soft and smooth and is the source 
of little irritation. 

Pathology. — McWilliams gives the following classification 
of the carcinomata of the appendix, and the frequency 
of occurrence of the different types: 

Spheroidal-cell carcinoma 53.5 per cent. 

Columnar-cell carcinoma 22.5 " 

Transitional 9.8 " 

Mixed 5.6 

Colloid 4.2 

Endotheliomata 4.2 " 

99.8 " 

Metastases. — In McWilliams' series, carcinomatous 
glands were demonstrated microscopically in only 1 
case. There were enlarged glands in 8 cases, but in 4 
cases they were not malignant, and in 3 cases no micro- 
scopic examination was made. Metastases in other 
organs practically are never seen. 

Extension of the Growth. — Carcinoma of the appendix 
long remains a local disease. Microscopically it may 
extend through the various layers of the appendix and 
on to the mesentery, and from this extension, the neigh- 
boring intestines and peritoneum may be involved. The 
growth may extend to the cecum, and it is probable 
that some cases considered to be primary in the cecum 
really began in the appendix. Even if the growth has 
apparently spread from the appendix to the cecum, 
it may continue its benign course. One case reported 



DURATION OF SYMPTOMS 271 

by McWilliams was considered at the first operation 
to be an inoperable malignant growth in the intestine 
and the abdomen closed. Twenty months later the 
abdomen was reopened, the appendix and some glands 
were removed for examination. The appendix contained 
a spheroidal-celled carcinoma but the glands showed 
no signs of malignant disease. Nine years later this 
patient Avas alive and in perfect health. The case illus- 
trates the benign clinical course of carcinoma of the 
appendix. 

Situation of the Tumor. — In the series of MacCarty 
and McGrath the growth was situated at or near the tip 
of the appendix in over 90 per cent, of the cases. In the 
series of McWilliams, it was situated at or near the tip 
in 59 per cent., in the middle in 14 per cent., near the base 
in 14 per cent, of the cases. It was situated distal to the 
middle of the appendix in 76 per cent, and proximal to 
the middle in 15 per cent., and involved nearly the whole 
•of the appendix in 8 per cent, of the cases. That is, the 
growth occurs usually in the outer half of the appendix. 
There seem to be a direct relationship between the location 
of the carcinoma and the site of a stricture or obliteration 
of the lumen. 

In 5000 cases reported by MacCarty and McGrath, 
carcinoma of the appendix was found in 1.6 per cent, of 
the cases in which there was a complete or partial oblitera- 
tion of the lumen. It is probable that this cicatricial 
change in the appendix is an etiological factor in the 
development of a carcinoma. 

Duration of Symptoms. — Of the cases in the series of 
MacCarty and McGrath, the duration of symptoms was 
one year or less in 1 1 cases, one to two years in 4 cases, 
two to three years in 2 cases, three to four years in 5 
cases, and four or more in 14 cases. One case of five 
years of age had had symptoms since birth. These 
Statistics cannot be interpreted to mean that carcinoma 
existed in the appendix for the periods given before it 
was removed. Previous to the development of the car- 



272 CANCER OF THE RECTUM 

cinoma there probably existed a chronic appendicitis which 
was the cause of the early symptoms. 

Symptoms. — In the early stage the symptoms of carcin- 
oma of the appendix are the symptoms of chronic appen- 
dicitis, with recurring acute attacks. The diagnosis 
is never made previous to operation and rarely even at 
the operation but the condition is found in the laboratory 
by routine examination of all appendices removed. 

In the late stage, the symptoms resemble those of 
carcinoma of the cecum, but probably without signs of 
obstruction. A tumor may be palpated in the right iliac 
region. Such a tumor may be composed of the primary 
tumor in the appendix with its extension to the cecum, 
and the small intestine adherent to it, the whole forming 
an irregular and indefinite mass. The tumor may be an 
abscess resulting from the perforation of the appendix 
by extension of the growth. 

Prognosis. — This is so favorable that carcinoma of the 
appendix is clinically an early benign tumor. McWilliams . 
reports only one case that was known to have recurred. 
The operative risk is that of appendicitis, for which the 
operation was performed, and it is not changed by the 
carcinoma. 

Treatment. — This is, of course, the surgical removal 
of the appendix. As has been stated, this is usually 
done for appendicitis without the diagnosis of carcinoma 
having been made. If a carcinoma were suspected, the 
mesentery should be divided at a distance from the 
appendix. If the growth involves the base of the appen- 
dix, a piece of the cecum should be removed. 

CANCER OF THE RECTUM. 

Etiology.— Frequency. — In Bashford's mortality statis- 
tics, primary malignant growth of the rectum was the 
cause of 7 per cent, of a total of 84,448 cancer deaths. 
Clogg states that about 3 per cent, of primary cancers 
occur in the rectum. In one series of cases reported 



ETIOLOGY 273 

by Mayo, carcinoma was found with practically the same 
frequency in the rectum as in the large intestine. 

Age. — As in cancer in other parts of the body, carcinoma 
of the rectum is most frequently a disease of middle 
and advanced age. Seventy per cent, of the cases are 
between the ages of forty and seventy years; 50 per 
cent, of the cases are between the ages of fifty and sixty- 
five years. More frequently than in other organs, car- 
cinoma of the rectum occurs in early years. For example, 
Kammerer reported a case of carcinoma of the rectum in a 
child of six months. Grulee records an adenocarcinoma 
of the rectum in a girl, aged sixteen years, and refers 
to other younger cases in the literature. A possible 
explanation of the frequency of carcinoma of the rectum 
in early life is the occurrence of papilloma of the rectum 
in children and its conversion into carcinoma. 

Sex. — Carcinoma of the rectum occurs more frequently 
in males than in females. Some surgeons give the pro- 
portion of two to one. This ratio, however, is probably 
too high. In Bashford's mortality statistics, there were 
about 15 per cent, more deaths from cancer of the rectum 
in males than in females. This is not as would be expected 
from the etiology, as ulcers, hemorrhoids and constipation, 
which are considered possible causes of carcinoma of the 
rectum are decidedly more frequent in women than in 
men. 

The knowledge of the real cause of carcinoma of the 
rectum is as indefinite as that of the cause of carcinoma 
in other parts of the bod}''. There are, however, certain 
conditions and lesions which apparently are factors in 
the causation of cancer of the rectum. 

Rectal Polypi. — There seems to be no doubt that 
rectal polypi have an influence in the development of 
carcinoma of the rectum. Either as a result of a car- 
cinomatous degeneration of the polypus, or the engraft- 
ment of the carcinoma on the polypus, the benign growth 
is replaced by the malignant cancer. If, as is generally 
believed, a chronic, constantly repeated irritation or injury 
18 



274 CANCER OF THE RECTUM 

is a causative factor in the production of cancer, it is 
easy to accept that a rectal polypus may become a recta 
carcinoma. The polypus is under constant irritation 
both from the contraction of the bowel pulling on its 
pedicle, and from the passage of fecal matter through 
the rectum, and its change from a benign to a malignant 
condition is possibly the direct result. 

Rectal Ulcer. — This is another factor in the production 
of a carcinoma of the rectum. A chronic ulcer in any 
part of the body, particularly in the alimentary canal, 
may change and become malignant. The situation in the 
rectum where it is constantly irritated by the contraction 
of the bowel and the fecal matter probably favors the 
change. 

Stricture. — A benign stricture of the rectum is a fre- 
quent result of a syphilitic infection. Its influence in the 
development of cancer is probably the same as that of 
polypi, ulcers, etc. It is a lesion that is predisposed to 
frequent irritation and injury. 

Hemorrhoids. — The connection with either internal or 
external hemorrhoids is not easy to prove. With many 
cases of carcinoma of the rectum, particularly if the case 
is at all advanced, marked hemorrhoids are present. 
They may have preceded the rectal carcinoma, or they 
may be the result of it. Furthermore when the great 
frequency of hemorrhoids and the relative rarity of rectal 
carcinomata are considered, it must be accepted that the 
chance of any case of hemorrhoids developing a carcinoma 
of the rectum is slight. In most cases of hemorrhoids, 
however, in which there is a little bleeding with each 
movement of the bowels, and in those cases in which the 
hemorrhoids protrude through the anus and are constantly 
rubbed with the clothing, there exists a definite patho- 
logical lesion and a constantly repeated irritation — two 
important factors in the production of cancer. While 
it is not proved that hemorrhoids predispose to cancer of 
the rectum, there is certainly the possibility of it. 

An important fact in regard to hemorrhoids is the 



PATHOLOGY 275 

frequency with which a carcinoma of the rectum is 
is incorrectly diagnosed as a case of hemorrhoids. Mayo 
stated that nearly 15 per cent, of cases of carcinoma of 
the rectum coming for consultation had recently been 
operated on for supposed hemorrhoids. 

Constipation. — The influence of constipation in the 
production of carcinoma of the rectum is an indirect one. 
The retention of hard fecal matter in the rectum or its 
passage through the rectum can produce an irritation 
and repeated trauma that favor the formation of a car- 
cinoma of the rectum. This is more marked if there is a 
polyp, ulcer, or stricture present in the rectum. 

Pathology. — Sarcoma of the rectum is relatively rare. 
Tuttle in a series of 100 cases reported only 6 per cent, 
sarcomata. The more frequent form of malignant tumor 
of the rectum is the carcinoma, usually of the type of 
adenocarcinoma. The following table from Tuttle gives 
the varieties with percentages, in the 100 cases reported 
in his paper and is a fair average of the frequency of the 
different types: 

Adenocarcinoma 84 per cent. 

Colloid carcinoma 2 " 

Scirrhus carcinoma 2 " 

Malignant papilloma 2 " 

Sarcoma 6 " 

Epithelioma 4 " 

100 

The third portion of the rectum, that is, the portion 
just above the sphincter ani, and sometimes called the 
anal canal, is an inch to an inch and a half long and is 
lined will] flat or pavement-epithelium. From 4 to 
per cent, of the cases of cancer of the rectum originate 
in the anal canal and are epithelioniata. As a rule, 
epitheliomata are less malignant than adenocareinomata, 
but in the rectum they arc often more malignant than 
epithelioniata in other parts of the body. 

The first and second portions of the rectum extend from 



276 CANCER OF THE RECTUM 

the pelvic brim near the left sacro-iliac articulation to the 
anal canal. Together they are eight to ten inches long. 
The first four or five inches of the rectum, the so-called 
first part, is covered with peritoneum and is attached to 
the pelvis by the mesorectum. In this portion of the 
rectum, it is technically possible to remove a wider area 
of tissue than in the second portion which is practically 
covered but not surrounded by peritoneum and is attached 
directly to the sacrum without an intervening mesorectum. 
The result of removal of a carcinoma of the rectum is 
therefore more favorable, both as to immediate mortality 
and ultimate results, if it was situated in the first than 
if in the second part of the rectum. Both the first and 
the second portions of the rectum are lined with columnar 
epithelium and the variety of malignant tumor most 
commonly found here is adenocarcinoma. It begins most 
frequently on the anterior wall. 

' The growth usually commences as a flat, slightly 
elevated, thickening of the mucous lining of the rectum. 
During this early stage, as it gives few or no symptoms, 
it is rarely seen unless discovered by accident. These 
growths in the rectum have two marked tendencies, 
one is to early ulceration, the other is to growth around 
the gut causing stenosis and obstruction. 

The three prominent symptoms of carcinoma of the 
rectum, namely, pain, bloody discharge and obstruction, 
depend on these characteristics. 

In some cases the tumor is distinctly of a polypoid 
type. It may be the result of a carcinoma developing 
in a preexisting polyp of the rectum, or the result of the 
action of the bowel repeatedly forcing the growth with its 
basic attachments downward toward the anus as may be 
done to any mass in the rectum. In some cases, the 
growth is found outside of the anus. 

In addition to extending around the lumen of the gut, 
carcinomata of the rectum also extend longitudinally 
so that before death a number of inches of the bowel may 
be involved. Handley has shown that microscopically 



SYMPTOMS 2.77 

the longitudinal extension of the disease may be as much 
as six inches above the apparent limits of the growth. 
This fact is important because of its influence on the 
operative technique of the removal of the growth. 

Besides the circular and longitudinal growth of the 
disease, it may also, by direct extension involve the 
surrounding organs, such as the prostate and bladder in 
the male, and the vagina and uterus in the female. Coils 
of small intestine may become adherent to the rectum 
over the growth, and become involved secondarily by 
direct extension from the primary growth. This is not 
apt to occur until the disease is well advanced, as it 
presupposes that the growth has already involved the 
thickness of the rectal wall. 

If the growth is limited to the first and second portions 
of the rectum, the lymphatic extension is to the sacral 
glands; if to the third portion, to the inguinal glands. 
The liver is the most frequent organ involved by metas- 
tases. 

Symptoms. — Early. — Unfortunately many cases give 
no early symptoms at all and the case is well advanced 
before the condition is discovered. It is possible for a 
case of carcinoma of the rectum to have passed the oper- 
able stage before giving symptoms that would suggest its 
presence. 

The tendency of a carcinoma of the rectum is to ulcerate 
early and to extend around the gut producing a stricture. 
The three most common symptoms of cancer of the 
rectum, pain, bloody discharge, and increasing constipa- 
tion, are due to the stricture and ulceration. 

Constipation. — The increasing degree of constipation 
is the important characteristic of this symptom. This 
is caused by the tightening of the stricture. Stronger 
cathartics and finally, in some cases, operative interference 
are necessary to relieve the obstruction. As a rule the 
increasing constipation is gradual, but sometimes there 
is an acute intestinal obstruction necessitating immediate 
relict'. 



278 CANCER OF THE RECTUM 

Bloody Discharge.— A constant diarrhea may be asso- 
ciated with the constipation. A small liquid movement, 
composed of the fluid feces, blood, and mucus, and some- 
times pieces of the tumor tissue, may be passed 
immediately on rising in the morning and at frequent 
intervals during the day. There may be a constant 
desire for a movement but with little material to pass. 

Pain. — Usually pain is a late symptom and may be 
absent entirely. When present locally it may be the 
result of hard fecal matter being forced through the 
stenosis of the gut; it may be due to the involvement 
of the anus in the growth and late in the course of the 
disease it may be due to the extension of the growth 
outside of the rectum to the surrounding tissues. General 
abdominal pain may result from the obstinate consti- 
pation. 

Rectal Tenesmus. — This is a frequent and distressing 
symptom. It may be due to the irritation about the 
anus by the frequent movements, or it may be due to the 
involvement of the anus by the growth. 

Cachexia. — The general health of the patient usually 
remains unaffected until late in the disease. The patient 
is able to take and retain nourishment and there is no 
early loss of weight. Later, on account of increasing 
constipation, the absorption from the growth and possibly 
the formation of metastases, there is loss of appetite, 
failure of the general health, emaciation and weakness, 
that is, cachexia of a malignant disease. 

Duration. — The course of the disease is relatively slow. 
Some cases, particularly those of the scirrhus type, last 
three to five years. The medullary type is more rapid 
and usually terminates under two years. In young 
patients the growth is more rapid than in those of advanced 
years. 

Diagnosis. — The ringer and the proctoscope are impor- 
tant means for the diagnosis of carcinoma of the rectum. 
If the growth is within reach of the fingers, its char- 
acteristic feeling will establish the diagnosis. It is often 



TREATMENT 279 

possible to remove a piece of the growth to confirm 
microscopically the findings of the examining finger. 

The proctoscope or the sigmoidoscope is a valuable 
aid in the diagnosis of growths situated higher in the 
rectum. In addition to the direct vision of the tumor, 
a piece may be removed with long forceps for microscopic 
examination. 

The rule to make a digital examination of the rectum of 
all cases giving abdominal or pelvic symptoms, enabled 
the Mayos to discover five early cases of carcinoma of 
the rectum before they were sufficiently advanced to 
give symptoms, and is a good rule to follow. 

Treatment. — The treatment of cancer of the rectum 
will be considered under three headings — the precancerous 
lesion, the operable cases, and the inoperable cases. 

1. Precancerous Lesions. — The treatment of the pre- 
cancerous lesions is the prophylaxis of cancer of the rectum. 
Any lesion or any condition that may possibly have an 
influence on the formation of a malignant growth in the 
rectum should be remedied. The rectal polypi, ulcera- 
tions, strictures and hemorrhoids are subject to repeated 
trauma and should be cured or watched for the first 
sign of an early malignant growth. By the removal 
of these lesions the chance of the development of a rectal 
cancer is lessened. 

2. Operable Cases. — The treatment of an operable case 
of cancer of the rectum is its removal by surgical means 
in a thorough manner at the earliest moment possible. 
The operability of a case is determined, not alone by the 
limits of the growth in the rectum, but by the extent of 
the involvement of the surrounding tissue, the condition 
of the lymphatic glands, and by the presence of metastases. 
Mayo states that he has not seen a case of rectal carcinoma, 
locally removable, which was inoperable on account of the 
involvement of the lymph nodes, though a number of such 
eases, however, were inoperable on account of a metastatic 
deposit in the liver. II* the rectum is not movable, but is 
fixed by the extension of the growth to the tissues fastening 



280 CANCER OF THE RECTUM 

it to the pelvis or to the viscera situated anterior to it, 
the case should not be considered an operable case and 
no attempt should be made to remove the growth. The 
operability of a case may sometimes be determined by 
a simple examination without an anesthetic. The doubt- 
ful case, however, should have the benefit of a thorough 
examination under an anesthetic and an exploratory 
incision if necessary. 

The following table from Tuttle shows the duration 
of symptoms previous to operation in his series of 
100 operable cases. It also shows the increased opera- 
tive risk that is associated with the longer duration of 
symptoms: 







Mortality from operation. 


Under 3 months . 


. 17 per cent. 


21.4 per cent. 


3- to 6 


. 16 


6.6 


6 to 9 " 


. 8 


14.3 


9 to 12 


. 15 


15.4 


Over 12 


. 44 


22.2 



It will be noticed that the second highest operative 
mortality is in the group of cases in which the duration 
of symptoms was less than three months. Tuttle believed 
that this group was composed of cases of marked malig- 
nancy and in a short time the extent of the growth w T as 
so large that an extensive operation was necessary. 
Mayo states that a number of his cases were operable two 
years after the first symptoms w^ere noticed. 

For the operable case, that is, the case in which the 
growth is to be removed, there are four tj^pes of operation. 
They are the perineal, the sacral, the abdominal and the 
combined abdominal and perineal. 

The 'perineal operation is indicated in cases of carcinoma 
of the rectum limited to the anal canal, and in some 
cases not suitable for an abdominal operation, though the 
growth is situated higher in the rectum. 

In the sacral operation, of which the Kraske is an 
example, the rectum is reached posteriorly by the removal 
of the coccyx and a part of the sacrum. This approach 
is also selected for cases not suitable for an abdominal 



END RESULTS 281 

operation and gives a more extensive exposure of the 
rectum than the perineal operation. A preliminary 
colostomy may be done. 

In the abdominal or combined abdominal and perineal 
operation, the growth is approached through an abdominal 
incision, and may be completed either through this in- 
cision or through the perineal route. After the removal 
of the growth, the divided proximal end of the sigmoid 
may be anastomosed directly to the rectum, or it may be 
drawn down to the anus, or it may be drawn out in the 
inguinal region as a permanent colostomy. 

End Results. — The operative mortality of recent opera- 
tions, if all cases are included, is from 15 to 20 per cent. 
In 27 perineal and sacral operations, Mayo reports 7 
per cent, primary mortality, and in 44 abdominal and 
combined abdominal and perineal operations 20 per cent, 
primary mortality. Infection is the most frequent cause 
of death following operation. 

In regard to the ultimate results of the operative 
treatment of carcinoma of the rectum, it may be stated 
that the higher in the rectum the growth is situated, 
the better is the prognosis for a permanent cure. When 
situated in the anal canal, the removal of a cancer is 
associated with a small operative risk but on account 
of the anatomical relations of the part, the risk of early 
recurrence is great. If situated high in the rectum, the 
risk of removal of a cancer is high, but it is technically 
possible to remove the growth more widely and the 
percentage of permanent cures is greater. 

3. Inoperable Cases. — The treatment of inoperable 
cancer of the rectum is the treatment of its symptoms. 
The local treatment of the tumor is only of temporary 
benefit, but it may relieve sj'mptoms for a time. It has 
been suggested that the obstruction in the bowel by the 
growth may be relieved by curetting or cauterization. 
This would certainly be associated with the risk of pene- 
trating the bowel and also of spreading the cancer cells 
to the surrounding tissues. 



282 CANCER OF THE RECTUM 

The treatment of the constipation is both by laxatives 
and enemata. The laxatives used should be mild and 
changed frequently so that the bowel does not establish 
a tolerance for any one. The enemata should be given 
carefully with a soft rectal tube to avoid injury to the 
bowel. An enema of a bland oil or of ox gall, retained 
long enough to soften the fecal matter, facilitates its 
passage through the stricture. The diarrhea may be 
treated by rectal irrigations. 

The pain which is caused by the constipation is treated 
by the attention given to the constipation. The pain 
caused by the extension of the disease involving other 
structures, necessitates sedatives and anodynes in increas- 
ing doses. In the earlier stages aspirin, heroin, and codein, 
either ^separately or in combination, will be sufficient to 
relieve the suffering. Later in the course of the disease 
morphin will be necessary. It should be remembered 
that a cancer of the rectum, even after it is in an inoper- 
able stage, may continue for some months, and the use 
of morphin should be reserved as far as possible for its 
terminal stage. At this stage it should be used in sufficient 
doses to make the patient comfortable. 

If the rectal tenesmus is due to irritation from the 
discharge and the frequent movements, the condition may 
be helped by gently washing the bowel with warm water 
and by the injection of a bland oil. The application of 
heat or of ice will often relieve the condition. If the 
rectal tenesmus is due to the involvement of the sphincter 
ani it may ultimately be relieved by the destruction of 
the action of the muscle by the advancement of the 
disease. 

A colostomy is more effectual in relieving the symptoms 
of cancer but its mental effect on the patient is such 
that it should not be performed until necessary. It 
should not be postponed too long. It should be located 
in the inguinal region as it is there most easily cared 
for. It should be located sufficiently high in the colon 
not to become involved in subsequent extension of the 



END RESULTS 283 

growth and also to prevent prolapse of the intestine. 
It will give the patient great relief from distressing 
symptoms and much less discomfort than is at first feared. 



LITERATURE. 

Baltzer. Arch. f. klin. Chir., xliv, 717. 

Bjorkenheim. Zeit. f. Gyn., xxxvi, 1329. 

Brill. Amer. Jour. Med. Sci., vol. cxxvii. 

Cheney. Amer. Jour. Med. Sci., vol. cxxxix. 

Clogg. Choyce, System of Surgery. 

Cope. British Med. Jour., 1912, p. 753. 

Grulee. Surgery, Gynecology and Obstetrics, ii, 678. 

Handley. Lancet, 1911, p. 230 (?). 

Harte. Annals of Surgery, vol. xlvii. 

Jopson and White. Amer. Jour. Med. Sci., December, 1901. 

Kasemeyer. Deut. Zeit. Chir., cxviii, 205. 

Lecene. These de Paris, 1904. 

Libman. Amer. Jour. Med. Sci., cxx and cxxix, 813. 

McWilliams. Amer. Jour. Med. Sci., vol. cxxxv. 

MacCarty and McGrath. Annals of Surgery, 1914. 

Mayo. Annals of Surgery. Collected Papers, Mayo Clinic. 

Mayo. Collected Papers, Mayo Clinic, 1911, 1912. 

Moynihan. Cavendish Lecture, 1913. 

Powers. New York Medical Journal, January, 1911. 

Speese. Annals of Surgery, lxix, 729. 

Tuttle. New York Medical Journal, 1908. 



CHAPTER XL 

CARCINOMA OF THE GALL-BLADDER AND 

DUCTS. CARCINOMA OF THE LIVER, 

CARCINOMA OF THE PANCREAS. 

CARCINOMA OF THE GALL-BLADDER AND DUCTS. 

Carcinoma of the gall-bladder and ducts maybe primary 
or secondary. When secondary it is usually a part of a 
general abdominal carcinosis, sometimes an extension 
from one of the neighboring organs. Most frequently 
these organs from which the carcinoma has extended are 
the liver, stomach, pancreas, and duodenum. In many 
cases at autopsy it is not possible to determine in which 
organ the primary lesion existed, and an analysis of early 
symptoms is a better indication of its location than the 
direct examination. 

Primary carcinoma of the gall-bladder and ducts may 
occur in any of four different places: 

1. The gall-bladder and cystic duct. 

2. The hepatic duct. 

3. The common bile duct. 

4. The papilla of Vater. 

Frequency. — Carcinoma of the gall-bladder itself is 
more frequently seen than that of the ducts. Of the 
ducts, the common bile duct is most frequently involved. 

At the Mayo Clinic, in about 4000 operations on the 
gall-bladder and biliary ducts, about 2.25 per cent, were 
for malignant conditions. This, however, probably does 
not indicate correctly the relative frequency of malignant 
disease of the gall-bladder and ducts. Relatively more 
cases of malignant disease of the gall-bladder and ducts 



AGE 285 

have passed the operable stage before coming under proper 
surgical care than of other conditions in these organs. 

In Musser's series there were 100 cases of carcinoma of 
the gall-bladder and 18 cases of carcinoma of the biliary 
ducts. This probably gives the relative frequency with 
which the gall-bladder and its ducts are involved. 

Williams considered that carcinoma of the gall-bladder 
is exceedingly rare. As evidence of its rarity, he states 
that among 7297 cancer patients in large London hospitals, 
he found only 11 cases of primary carcinoma of the gall- 
bladder. He also quotes Guilt, who found only 5 cases 
among 11,131 cancer patients in the Vienna hospitals, 
and Reiche, who, from mortality statistics of Hamburg, 
found 48 cases among 12,484 cancer deaths. It is hardly 
possible that these figures even approximately indicate 
the frequency of the occurrence of carcinoma of the 
gall-bladder. The natural explanation of them is that 
the early cases are not diagnosed clinically, and in the 
late cases the location of the primary lesion cannot be 
determined. 

In Bashford's mortality statistics, malignant growths 
of the liver and of the gall-bladder are grouped together. 
Among 84,488 cancer deaths there were 11,531 recorded 
cases, or 13.6 per cent, of malignant growths of the liver 
and gall-bladder. This percentage of malignant growths 
of the liver and gall-bladder is undoubtedly too high, and 
probably a number of secondary growths in the liver were 
included. Secondary malignant growths in the liver are 
frequent; they are easily diagnosed, and easily obscure a 
less prominent primary lesion. 

Age. — The average age of primary carcinoma of the 
gall-bladder is later than that of most carcinomata; the 
largest number occur between fifty and seventy years 
of age. 

In Futterer's series the youngest case was twenty-five 
and the oldest ninety years of age. 

The following table gives the ages in 247 cases of car- 
cinoma of the gall-bladder in Futterer's series. 



286 CARCINOMA OF GALL-BLADDER AND DUCTS 

Age. Number of cases. 

20 to 29 years 5 

30 to 39 " 20 

40 to 49 " 44 

50 to 59 " 69 

60 to 69 " 67 

70 to 79 " 37 

80 to 89 " 4 

90 " 1 

247 

Five-eighths of Rolleston's 83 cases of primary carcinoma 
of the biliary ducts were more than fifty years of age. 
One case of Musser's series was under ten years of age. 

Sex. — Carcinoma of the gall-bladder occurs more fre- 
quently in women than in men. In Musser's and in 
Fiitter-er's series there were three or four times as many 
cases in women as in men. This proportion is of interest 
when it is remembered that gall-stones occur much more 
frequently in women than in men, and that they are 
probably the most important factor in the causation of 
carcinoma of the gall-bladder. 

Carcinoma of the biliary ducts differing from carcinoma 
of the gall-bladder is more frequent in men than in 
women. For example, Miodowski in 40 cases of carcinoma 
of the common bile duct collected from the literature 
found that 26 cases were men and 14 cases women. He 
also states that Schultze found in 17 cases of carcinoma 
of the hepatic duct there were 12 cases in men and 5 
cases in women. In 85 cases of malignant disease of the 
biliary ducts reported by Rolleston there were 50 males 
and 35 females. 

Gall-stones. — The frequency with which gall-stones 
are found associated with carcinoma of the gall-bladder, 
and the evident chronic irritation and inflammation that 
are associated with them, leaves little to be desired for 
positive proof, that the carcinoma of the gall-bladder is 
the direct result of the gall-stones. This connection 
between the two conditions is universally accepted. 
Carcinoma of the gall-bladder resulting from gall-stones 



PATHOLOGY 287 

is one of the best examples of a malignant disease result- 
ing from chronic irritation. 

Fiitterer in 209 cases of carcinoma of the gall-bladder, 
found gall-stones in 75 per cent.; Musser in 69 per cent. 

The fact that carcinoma of the gall-bladder occurs most 
frequently at its fundus, which is its lowest part, and there- 
fore the point most likely to be irritated by gall-stones, 
and, secondly, at the beginning of the cystic duct where 
a gall-stone is apt to become impacted, is additional evi- 
dence of the influence of the gall-stones in the causation 
of carcinoma of the gall-bladder. 

Williams does not believe that gall-stones are the cause 
of cancer of the gall-bladder. It is his belief that cancer 
of the gall-bladder is a very rare disease, occurring only 
11 times in 7297 cancer cases, and that if it were caused 
by gall-stones it would be found more frequently. As 
has been stated, it is probable that Williams' figures 
do not indicate the frequency of carcinoma of the gall- 
bladder. 

It has been suggested that the gall-stones are the result 
and not the cause of carcinoma of the gall-bladder. 
Against this, as stated by Wolff, is the fact that in primary 
carcinoma of the gall-bladder, stones are present in nearly 
90 per cent, of the cases, but in only 15, or 16 per cent., of 
the secondary cases. Additional evidence is the large 
size or number of gall-stones that are sometimes found 
with a small malignant growth. 

Gall-stones are not present in carcinoma of the biliary 
ducts in the same frequency as in carcinoma of the gall- 
bladder. In 67 cases of Rolleston's gall-stones were 
present in 2'.] and absent in 44 cases. It is possible that 
they may have been there but had been passed previous 
to the examination. 

Pathology.— In most cases carcinoma of the gall-bladder 
is of the columnar variety. Epitheliomata are occasionally 
seen. For example, Diet/ reports 1 eases. 

Sarcoma of the gall-bladder is more rare than carcinoma 
and only a lew cases are reported in the literature. 



288 CARCINOMA OF GALL-BLADDER AND DUCTS 

The malignant growths of the biliary ducts are prac- 
tically all of the columnar-celled variety. 

The location of the malignant growth in the biliary 
ducts in 90 cases is given by Rolleston as follows: 

Common bile duct 35 

Junction of common bile duct, cystic and hepatic ducts 27 

Hepatic duct 22 

Cystic duct 6 

90 

The growth in the bile ducts is usually small and limited 
to a part of the duct, and may cause a stricture. In some 
cases the growth is more diffuse. The obstruction of the 
biliary duct may be due to the annular stricture or to 
the filling of the lumen by the growth. 

If the growth is in the hepatic duct, it extends early 
to the liver; if in the cystic duct, to the gall-bladder; and 
if in the lower end of the common bile duct, to the head of 
the pancreas or to the duodenum. If the case is not seen 
early, it may be difficult to determine the primary location. 

Though local extensions are common, secondary deposits 
and metastases are not usually present on account of the 
rapid course of the disease and its termination before they 
are formed. 

Unless there is present other cause of obstruction, such 
as an impacted gall-stone, the bile ducts below the growth 
are normal; above it they are dilated. 

Symptoms of Carcinoma of the Gall-bladder.— A previous 
history of gall-stones is usually present. Most early 
diagnoses are made only at an operation for gall-stones, 
as in many cases there are no symptoms that will allow 
a differential diagnosis to be made between the two 
conditions. 

Pain. — A dull pain referable to the region of the gall- 
bladder is usually the first symptom. It may be referred 
to the stomach or to the appendix. The pain may be 
sharp and stabbing and increased by position and exercise. 
The pain may be in the form of biliary colic. This may 



SYMPTOMS OF CARCINOMA OF GALL-BLADDER 289 

be due to the presence of gall-stones, which may or may 
not have given symptoms previous to the development 
of the carcinoma. 

In addition to the pain, there may be distinct tender- 
ness over the gall-bladder due to an inflammatory con- 
dition in or about the gall-bladder. Musser found pain 
in 62 per cent, of the cases in his series. 

Tumor. — A tumor below the liver is present in 50 to 75 
per cent, of the cases, depending on the stage of the disease 
at which the case is examined. If not adherent to sur- 
rounding structures the tumor moves with the diaphragm 
and possibly also from side to side. In the early stages 
the tumor is smooth and elastic, but later it is hard and 
nodular. This may be a diagnostic point of value between 
primary malignant disease of the gall-bladder and that 
of the biliary ducts. It may become adherent to the 
abdominal wall and become immovable. The tumor is 
usually in the right hypochondrium, but it may be in the 
umbilical region if the liver is enlarged or displaced. 

Vomiting and Diarrhea. — These symptoms are usually 
present during some stage of most cases. When the vomit- 
ing starts it usually persists. 

Jaundice. — Jaundice was present in 69 per cent, of 
the cases in Musser' s series. It may be due to gall-stones 
or to an inflammatory condition, or to the carcinoma. 
If due to the extension or to the pressure of the new 
growth it is usually continuous and progressive. If due 
to an inflammatory condition or to gall-stones it may be 
intermittent. 

Interference with the general health may be the first 
indication of malignant disease of the gall-bladder. Rapid 
loss of flesh and strength follow quickly after the onset 
of the disease. Anemia is marked, but its appearance 
in the skin may be obscured by the jaundice. In the 
last stages the patient may become drowsy and finally 
comatose. 

Ascites. — Ascites occurs, according to Rolleston, in 
25 per cent, of the cases. It is not due to the malignant 
19 



290 CARCINOMA OF GALL-BLADDER AND DUCTS 

growth in the gall-bladder, but to the secondary growths, 
particularly the chronic peritonitis due to metastases in 
the peritoneum. It may be due to pressure on the portal 
vein. 

Duration. — The disease usually terminates within six 
months or a year. 

Complications. — The gall-bladder may rupture, causing 
a fatal hemorrhage, a general peritonitis, or a general 
abdominal carcinosis. The gall-bladder may become 
infected and cause a general peritonitis. By extension 
of the disease there may be obstruction in the duodenum 
or in the colon. 

The symptoms of carcinoma of the cystic duct are prac- 
tically the same as those of carcinoma of the gall-bladder. 
The symptoms of carcinoma of the hepatic duct are 
practically the same as those of the liver. 

Symptoms of Carcinoma of the Common Bile Duct. — 
Jaundice. — Rolleston states that jaundice is usually the 
first symptom. As a rule it precedes pain. The jaundice 
is progressive and becomes very marked. At the onset 
it may be associated with the gastro-intestinal distur- 
bances that accompany the interference of the passage 
of the bile into the intestines — that is, with nausea, 
vomiting, constipation, clay-colored stools, etc. 

The jaundice differs from that of catarrhal jaundice 
in being more persistent. Catarrhal jaundice usually 
disappears spontaneously or as a result of treatment in 
a few weeks. That due to a malignant disease steadily 
progresses. 

Pain. — Pain may be dull in character and referred to 
the right hypochondrium or to the epigastrium, or there 
may be attacks of biliary colic. 

Gall-bladder. — The gall-bladder is usually distended 
and can be palpated unless obscured by ascites. 

Course. — This is usually rapid. The duration of life 
after the appearance of the jaundice is rarely more than 
six months. This fact is of value in excluding malignant 
disease of the biliary ducts in cases of jaundice of longer 



CARCINOMA OF THE AMPULLA OF VATER 291 

duration. If the malignant growth involves the cystic 
duct alone, there is ordinarily no jaundice. 

Treatment of Carcinoma of the Gall-bladder and Ducts. — 
The disease is necessarily fatal unless it is removed. 
If the growth is limited to the gall-bladder it can be suc- 
cessfully removed, though the mortality is high and an 
early recurrence is the usual result. It is probable that 
most cases of successful removal of the gall-bladder for 
carcinoma were operated upon for gall-stones and the 
carcinoma was found accidentally. 

In a few cases a malignant growth has been removed 
from the bile duct. The operation is one of difficulty and 
with a high surgical risk. 

An anastomosis of the gall-bladder to the intestines 
to overcome an obstruction in the common bile duct may 
relieve the symptoms for a time. 

The pain and the gastro-intestinal disturbances may 
require medical treatment. 

CARCINOMA OF THE AMPULLA OF VATER. 

The papilla or ampulla of Vater is formed by the junc- 
tion of the main pancreatic duct and the common bile 
duct and opens into the middle portion of the duodenum. 

Carcinoma of the ampulla of Vater must be distin- 
guished, according to Rolleston, from (1) carcinoma of 
the termination of the common bile duct, (2) from car- 
cinoma of the termination of Wirsung's duct, and (3) 
from carcinoma of the duodenum which involves the 
ampulla of Vater secondarily. Obviously, excepting in 
a very early stage of the disease, it would not be possible 
to locate exactly the anatomical part in which the tumor 
originated, and doubtless many cases described as car- 
cinoma of the ampulla of Vater would not stand this 
severe test. 

Carcinoma of the ampulla of Vater is practically 
always the columnar variety — that is, the same as found 
in the bile ducts. 



292 CARCINOMA OF THE LIVER 

As the carcinoma increases it early forms an obstruction 
in the pancreatic duct or to the common bile duct, or to 
both. The tumor is small, and secondary growths are 
unusual on account of the early termination of the disease. 

Age and Sex. — In both age and sex, carcinoma of the 
ampulla of Vater corresponds to carcinoma of the bile 
ducts. It is more common in men than in women. Of 
19 cases collected by Rolleston 14 were men, 5 women. 

The average age in Rolleston's 19 cases was 55.2 years; 
the extremes were thirty-four and eighty-one years. 

Gall-stones. — In only 2 of Rolleston's cases gall-stones 
were present, which suggests that they have not the 
same causative influence here as in the gall-bladder. It 
is possible that they may have been present and passed 
into the intestine. 

Symptoms. — The symptoms of carcinoma of the ampulla 
of Vater depend on the interference with the functions 
of the pancreatic and common bile ducts and in a late 
stage, if the duration of the disease is sufficient, of the 
duodenum. 

Treatment. — Surgically the growth may be removed 
either by resecting the duodenum or by excision. Oehler 
reports a case alive and well three years and nine months 
after the removal of such a growth. 

The medical treatment is entirely symptomatic and 
similar to that for carcinoma of the common bile duct. 



CARCINOMA OF THE LIVER. 

Carcinoma of the liver may be primary or secondary. 
Primary carcinoma is rare. Eggel estimated that pri- 
mary carcinoma was found once in 2000 autopsies. 

Sex. — In Rolleston's series of 42 cases of primary car- 
cinoma of the liver there were 29 males and 13 females. 
In Eggel's cases the proportion was practically the same 
as in Rolleston's cases. 

Age. — The average age of 42 cases collected by Rolleston 
was 47.2 years. It is rare before forty years of age, but 



PATHOLOGY 293 

may occur at any age. P. W. Phillips collected from the 
literature 11 cases of primary carcinoma of the liver in 
children and added one of his own, all of which he believed 
to be genuine cases. It is probable that some cases re- 
ported as carcinoma of the liver in children, are multiple 
adenomata and not carcinomata. 

Etiology. — Cirrhosis of . the Liver. — This is generally 
considered to be a predisposing cause of carcinoma of 
the liver, though some observers regard it as a result. 
The two conditions are certainly frequently found 
together. Secondary carcinoma more frequently than 
primary carcinoma of the liver is not associated with 
cirrhosis. Rolleston believes that the cirrhosis causes 
a compensatory hyperplasia of the liver cells, and in 
some cases this change passes into carcinoma. 

Multiple adenomata of the liver is a condition in which 
there is a hyperplasia of the liver cells, and an increase in 
the connective tissue, such as is seen in cirrhosis of the 
liver. By some it is believed that the hyperplasia is the 
result of the cirrhosis, by others that both conditions 
result from the same cause. The former belief is more 
generally accepted. 

The point of interest is the relationship of the adeno- 
mata to primary carcinoma of the liver. Multiple adeno- 
mata of the liver are believed to be an intermediate stage 
between cirrhosis and carcinoma. That is, that the cir- 
rhosis causes the compensatory hyperplasia of the liver 
cells and later the adenomatous nodules become malignant. 

Trauma. — A number of cases of carcinoma of the liver 
have been reported which were believed to have resulted 
from traumatism. The cases of primary carcinoma of 
the liver are so infrequent it is difficult to trace the direct 
connection between an injury and the malignant growth. 
The liver is so well protected by the chest wall that the 
occurrence cannot be frequent. 

Pathology. — Primary carcinoma of the liver originates 
either in the liver cells or in the lining of the small biliary 
ducts, or of the larger bile ducts. 



294 CARCINOMA OF THE LIVER 

Primary carcinoma of the liver occurs in several forms. 

I. Primary Massive Carcinoma. — There is a single 
rapidly-growing mass of carcinomatous tissue which 
pushes the liver tissue before it, and which does not show 
the same tendency to infiltrate the liver as the diffuse 
form. That is, it remains more localized. There may be 
secondary nodules in the liver. The liver is considerably 
but irregularly enlarged especially on the right side. 

II. Primary Infiltrating or Diffuse Carcinoma. — This 
forms a diffuse infiltration of a large part of the liver. 
There is a large amount of fibrous tissue. The liver may 
not be enlarged and it may have in general the appear- 
ance of a cirrhotic liver. 

III. Nodular or Multiple Primary Carcinoma. — In 
this form there are multiple nodules throughout the liver 
and the appearance of the liver is similar to that seen in 
secondary carcinoma of the liver. It is possible or prob- 
able that one nodule was primary and the others secondary 
to that nodule, or that the primary growth was in another 
organ and not detected on account of its small size. 

In these cases there was frequently, first, a cirrhosis 
of the liver, and the carcinoma resulted from it, though 
some observers believe that the carcinoma was the original 
lesion and caused the cirrhosis. 

The cirrhosis is extensive and involves the entire organ. 

Secondary Carcinoma of the Liver. — This condition is 
more common than primary carcinoma of the liver in 
the proportion of at least 1 to 20 and possibly 1 to 40. 
It occurs more frequently in women than in men, probably 
because women are more often the victims of carcinoma, 
and especially in organs, such as the breast and uterus, 
from which secondary growths in the liver are especially 
frequent. 

The secondary growths in the liver are practically 
always multiple and usually scattered throughout the 
organ. The liver is usually increased in size and may 
be very large. The surface is rough and studded with 
hard, white, carcinomatous nodules. 



SYMPTOMS OF CARCINOMA OF THE LIVER 295 

Symptoms of Primary and Secondary Carcinoma of the 
Liver. — Whether primary or secondary, the symptoms 
of carcinoma of the liver depend on the extent of the 
disease, and the involvement of surrounding organs. In 
the earliest stage there are no symptoms directly referable 
to the liver, and the liver condition may even be well- 
marked before it gives S3 r mptoms. In many cases of 
secondary carcinoma of the liver the symptoms are due 
entirely to the primary lesion and the liver deposit is 
discovered only at autopsy. 

In primary carcinoma of the liver the early symptoms 
may be general weakness, loss of weight and strength, 
and only at a later stage is the location of the disease 
recognized. 

Liter. — The size of the liver is usually increased. In 
some cases the increase in size is so great that the liver 
seems to fill a large part of the abdomen. The surface 
of the liver may be nodular or irregular. It is more 
often smooth in primary than in secondary carcinoma. 
The right side is more often enlarged than the left. The 
liver usually moves with respiration, but may become 
adherent to the abdominal wall. 

The enlargement of the liver is steadily progressive, 
and usually rapid. The great vascularity and physiologi- 
cal activity of the organ doubtless favors the rapid increase 
of the malignant growth. This may be further accelerated 
by hemorrhage into it. 

In some cases, especially in the massive variety, the 
growth may be so soft that it fluctuates and resembles 
an abscess. The tendency for the growth to increase at 
the periphery, frequently gives a depressed centre or 
umbilicated form that is characteristic. 

Ascites. — This is present in one-half of the cases at 
some stage of the disease. It may be caused (1) by peri- 
toneal irritation due to extension of the disease to the 
peritoneum covering the liver or to a secondary deposit 
elsewhere in the abdominal cavity, or (2) to obstruction 
to the capillaries inside the liver, or (3) pressure on the 



296 CARCINOMA OF THE LIVER 

portal vein by extension of the primary or by a secondary 
growth. 

The ascitic fluid is usually clear in color, but if jaundice 
is also present it is yellow, and if intraperitoneal hemor- 
rhages have occurred it may be bloody. 

Jaundice. — This is a frequent symptom, being present 
in about 50 per cent, of the cases. It is usually due to 
mechanical obstruction from pressure either on the 
common bile duct or less frequently to pressure on the 
larger intrahepatic ducts. Jaundice produced in this 
way usually begins gradually but is steadily progressive 
and becomes marked if the disease is. sufficiently prolonged. 
In some cases the onset of jaundice is sudden. The 
abrupt onsets may be caused by a hemorrhage into the 
growth causing a sudden increase in its size. A catarrhal 
jaundice may develop in the early stage of the disease 
and subside. This is probably the explanation of some 
cases of intermittent jaundice seen with carcinoma of the 
liver. 

Pain. — Pain is not a marked symptom in carcinoma of 
the liver. Local discomfort and a sense of weight from 
the increased size of the liver are more frequent symp- 
toms. When pain is present it is probably due to a peri- 
hepatitis and to the peritoneal irritation from the rough 
surface of the movable liver. 

Cachexia. — The onset of cachexia is rapid and pro- 
gressive. There is marked emaciation, which is particu- 
larly noticeable in the face and extremities, in contrast 
with the abdomen, which may be distended by the 
enlarged liver and the ascites. 

Duration. — White states that the duration of primary 
carcinoma of the liver is usually less than four months. 
The duration of the secondary carcinoma of the liver 
depends on the nature of the primary lesion, which may 
terminate the life of the patient shortly after the involve- 
ment of the liver occurs or is noticed. In other cases 
life may be prolonged longer than is usual for a primary 
carcinoma. 



CARCINOMA OF THE PANCREAS 297 

Treatment. — The treatment is entirely symptomatic. 
A few cases have been operated upon and the growth in 
the liver removed. This, however, is not often done, 
and it is doubtful if any real benefit can be secured with 
the present knowledge of operative technique. 

CARCINOMA OF THE PANCREAS. 

Frequency. — Carcinoma of the pancreas is a frequent 
form of malignant disease. In Bashford's statistics, in 
a total of 84,448 deaths from malignant disease in 1901, 
1902, and 1903, there were 526 males and 474 females, 
or about 12 per cent., who died of primary malignant 
disease of the pancreas. These cases include both car- 
cinomata and sarcomata. It is not easy in the terminal 
stage in all cases to determine the exact location of the 
primary lesion and it is possible that in the cases reported, 
some were secondary growths. 

Age. — In Bashford's statistics there were 6 cases under 
twenty-five years of age, and the largest number of cases 
were in the decade between fifty-five and sixty-five years. 
Cases in earlier years are reported in the literature. Wolff 
refers to a case of primary carcinoma of the pancreas re- 
ported by Kiihn and another by Sotow in children under 
two years of age. 

Sex. — Carcinoma of the pancreas is more common in 
men than in women. In Bashford's statistics in 1000 
cases of primary malignant disease of the pancreas 526 
were men and 474 were women. Of the cancer deaths 
in men, one in 64 and in women, one in 107 were from 
primary malignant disease of the pancreas. 

Description. — The variety of primary carcinoma is 
most frequently scirrhus, others, such as medullary, col- 
loid carcinoma, and epithelioma, have been described. 

Usually the growth starts in the head of the pancreas, 
but frequently at the time of the examination it has 
involved the entire gland. 

The most frequent metastases from carcinoma of the 



298 CARCINOMA OF THE PANCREAS 

pancreas are in the liver. A number of writers have noted 
that the deposits in the liver, secondary to carcinoma of 
the pancreas, are usually of small size. By direct exten- 
sion the growth most frequently involves the stomach, 
duodenum, and common bile duct, and the symptoms 
frequently depend on the secondary involvements. The 
secondary involvements of the pancreas from these same 
organs, the stomach, duodenum, and bile ducts, are 
frequent. Undoubtedly many cases reported to be pri- 
mary in the pancreas were really secondary to the growths 
in other organs. When the growth is in an advanced 
stage, such as is seen frequently at autopsy, it is not 
possible to state in which organ the growth started. 

Symptoms.— Pain. — This is one of the earliest and 
most constant symptoms of carcinoma of the pancreas. 
It is usually referred to the epigastrium, but may radiate 
to the back. It may be caused by pressure of the growth 
on the celiac ganglion and its branches or on the pancreatic 
or common bile duct. If the pain is due to pressure 
on the celiac ganglion and its branches, it is usually severe 
and increases in intensity. If the pain is due to pressure 
on the pancreatic or common bile duct it may be inter- 
mittent and colicky in character. 

Tumor. — A tumor can be palpated in about 25 per 
cent, of the cases, and is usually in the epigastrium. It 
may be either to the right or the left of the middle line. 
It is deep-seated and may be obscured by a thick, abdom- 
inal wall. It may pulsate with the aorta. 

Jaundice. — As carcinoma of the pancreas is most 
frequently situated in the head, obstruction to the com- 
mon bile duct with the resulting jaundice is of frequent 
occurrence. Carcinoma of the pancreas is one of the 
most frequent causes next to gall-stones, of obstruction 
to the common bile duct. It may be one of the earliest 
symptoms. Usually the jaundice is steadily progressive 
and becomes very marked before death. There may be 
no jaundice in cases starting in the body or tail of the 
pancreas. 



TREATMENT 299 

Gall-bladder. — The condition in the gall-bladder depends 
on the obstruction to the common bile duct. As a rule 
the gall-bladder is usually dilated when the obstruction 
is due to a malignant process and contracted when due 
to a gall-stone. The gall-bladder follows this rule and is 
usually dilated in cases of carcinoma of the pancreas. 

Liver. — The liver is not usually enlarged. The secon- 
dary deposits in the liver, it is stated, are not as large as 
secondary growths from malignant growths in other 
organs. Miraillie found the liver enlarged only seventeen 
times in a series of 113 cases. 

Gastro-intestinal Tract. — The disturbance of the gastro- 
intestinal tract may precede all other symptoms. There 
may be nausea and vomiting, loss of appetite, distaste 
for food, etc. If the growth extends to the pylorus it 
may be obstructed, causing dilatation of the stomach. 

By obstruction of the pancreatic duct, or by destruc- 
tion of the pancreatic tissue, there may be a lack of pan- 
creatic juice in the intestines. It is believed that this 
causes fatty stools, that are sometimes seen in cases of 
pancreatic carcinoma. 

Diabetes mellitus may appear in a late state of pan- 
creatic carcinoma when the pancreas is largely destroyed 
by the growth. 

Cachexia. — This is usually rapid in its progress. The 
mechanical obstruction of the growth to the pancreatic 
and common bile ducts, stomach and intestines and the 
growth of the tumor and metastases in vital organs all 
add to the cachexia. The rapid course of the cachexia 
is of diagnostic value. 

Duration. — This is short, usually lasting only a few 
months. Opie, however, states that the duration of the 
disease may be two or more years. These cases are 
exceptional. 

Prognosis. — This is always unfavorable. 

Treatment. — The medical treatment is largely the 
relief of symptoms. The administration of trypsin, or a 
pancreatic extract, may assist in digestion when there is 



300 CARCINOMA OF THE PANCREAS 

an absence of pancreatic juice in the intestines. Mor- 
phin will probably be necessary for the pain early in the 
disease. 

The surgical treatment is usually directed to relieving 
the complications. The obstruction to the common bile 
duct and distention of the gall-bladder may be benefited 
by a cholecystenterostomy. The results of the surgical 
removal of the growth itself are not favorable, though it 
has been done in a number of cases. The primary mor- 
tality is very high and life is not greatly prolonged. 



LITERATURE. 

Dietz. Virchows Arch., Bd. 164, S. 381. 

Eggeh Beitr. z. path. Anad., 1901, xxx, S. 506. 

Freidheim. Beitz. klin. Chir., Bd. 44, S. 188. 

Futterer. Ueber die Aetiologie des Carcinoma. 

Mayo. Collected Papers, 1910. 

Miodowski. Virchows Arch., Bd. 169, S. 117. 

Musser. Boston Med. and Surg. Jour., vol. cxxi, pp. 525, 553, 581. 

Phillips. Zeit. f. Krebsf., Bd. v, S. 357. 

Rolleston. Diseases of the Liver and Bile Tract. 

Siegert. Virchows Arch., Bd. 132, S. 253. 



CHAPTER XII. 

CANCER OF THE KIDNEY, BLADDER, 
PROSTATE, PENIS, AND TESTIS. 

CANCER OF THE KIDNEY. 

There is great obscurity in the pathology and classifica- 
tion of malignant tumors of the kidney. This trouble is 
caused largely by the difficulty in properly classifying the 
hypernephromata. Tumors, having practically the same 
histological characteristics, are called by different observers 
alveolar sarcoma, perithelioma, endothelioma, angiosar- 
coma, etc., all of which would better be classified under 
hypernephromata. 

In the three varieties, hypernephromata, carcinomata, 
and sarcomata, are included most of the malignant 
growths of the kidney and of these sarcomata are very 
rare. 

Hypernephromata. — The origin of the hypernephromata 
is still in dispute. 

Grawitz, in 1883, was the first to give an accurate 
description of the hypernephromata. He believed them 
to originate in the adrenal "rests," and since the appear- 
ance of his article, this origin has been widely accepted. 
Those who accept the adrenal "rests" as the origin of 
hypernephromata believe that they definitely illustrate 
Cohnheim's theory of the development of the tumors 
from fetal inclusions because these adrenal "rests" are 
frequently seen in an early stage before the development 
of the hypernephromata. 

The evidence offered to prove that hypernephromata 
develop from adrenal "rests" is that they are more fre- 



302 CANCER OF KIDNEY, BLADDER, PROSTATE 

quently located in the upper pole of the kidney, where 
adrenal "rests" are most frequent, that the encapsulation 
of the tumor is similar to that of adrenal "rests;" that 
the character and arrangement of the cells is similar to 
that of the normal adrenal gland and unlike that of the 
kidney, and the fatty infiltration of the cells. 

The theory that hypernephromata develop from adrenal 
"rests" has been rejected by some observers. 

Sudeck believed that the tumors described by Grawitz, 
and now generally termed hypernephromata, were not 
derived from adrenal "rests," but were derived from renal 
tubules. Stoerk more recently has expressed his opinion 
against hypernephromata originating in adrenal "rests," 
but believes that they are carcinomata developing after 
an atrophic nephritis. Wilson has also expressed his 
belief that hypernephromata do not originate in adrenal 
"rests." He makes the following conclusions: 

"1. Most if not all so-called 'adrenal rests' are probably 
of Wolffian origin. 

"2. There is almost no evidence, embryological or his- 
tological, in support of Grawitz 's hypothesis that the 
so-called 'hypernephromata' have their origin in adrenal 
rests. 

"3. There is much evidence that the so-called 'hyper- 
nephromata' do not arise (according to Stoerk's hypothe- 
sis) from proliferations of the adult secreting epithelium 
of the convoluted tubules. 

"4. There is much evidence that the so-called 'hyper- 
nephromata' do arise from islands of nephrogenic tissue 
(primitive renal blastema). Such tissue is sometimes 
present in the adult kidney, and appears capable of form- 
ing tumors of the non-infiltrating, mixed-cordon, tubular, 
papilloform, and sarcoma type so characteristic of the 
so-called hypernephromata." 

The hypernephromata are usually surrounded by a 
definite capsule, which may be broken through in places. 
The formation of the growth varies in different parts 
of the tumor, in places it has a papillary form and in other 



CANCER OF THE KIDNEY 303 

places, tubular. The arrangement and character of the 
cells in different parts of the growth suggest carcinoma, 
sarcoma, and adenoma. 

The location of the growth may be in any part of the 
kidney parenchyma. Those who accept Grawitz's theory, 
and believe that hypernephromata develop from adrenal 
"rests," claim that these tumors are more common in the 
upper pole of the kidney. Wilson in a series of 48 cases 
found 12 to have originated in the upper pole, 14 in the 
middle, and 10 in the lower, and in 12 cases the exact 
location was indeterminable. 

The degree of malignancy of hypernephromata is in the 
same obscurity as their origin and histology. If it is 
accepted that they originate in the adrenal rests or fetal 
inclusions, then it is believed that they have existed for a 
long time as benign conditions, and later, as a result of 
injury or other excitant, took on the malignant quality. 

The hypernephromata are sometimes divided into 
benign and malignant, showing the uncertain knowledge 
of the growth. It is better that all hypernephromata 
should be considered as malignant growths and treated 
as such. If it is a benign growth it should not be classified 
with the usual group known as hypernephromata. 

The growth spreads by direct extension and by metas- 
tases. The metastases usually occur through the blood- 
vessels and more rarely through the lymphatic system. 
In Garceau's series the metastases occurred most fre- 
quently in the lungs and bones. 

Age. — The ages of 176 cases in a series reported by 
Garceau arranged by decades are shown in the following 
table : 

1 to 10 years 4 cases. 

10 to 20 " " 

20 to 30 " 10 " 

30 to 40 " 17 " 

40 to 50 " 48 " 

50 to 60 " 61 

60 to 70 " 24 " 

70 to 80 " 3 " 

Not stated 9 " 

17(1 " 



304 CANCER OF KIDNEY, BLADDER, PROSTATE 

The youngest was eighteen months and the oldest 
seventy-nine years of age. 

Sex. — Of the 176 cases in Garceau's series, 102 were 
males and 71 females, and in 3 it was not stated. Most 
writers state that hypernephromata are more frequent in 
males than in females, and in about the same proportion 
as in Garceau's series. 

Symptoms.— The three cardinal symptoms of a malig- 
nant tumor of the kidney are hematuria, pain, and tumor. 
They are not all necessarily present in all cases. 

Hematuria. — This is probably the most frequent and 
important of the three symptoms. 

The frequency of hematuria as a symptom of hyper- 
nephromata is seen in the statistics of many observers. 
In the 176 cases reported by Garceau, hematuria was a 
prominent symptom during some part of the disease in 
89, or one-half of the cases. In 61 cases, or 34.6 per cent., 
there had been no bleeding up to the time the history 
was taken. Young quotes the statistics of a number of 
observers which showed hematuria to be present in 50 to 
70 per cent, of the cases of hypernephromata. 

Garceau believes that the cause of hematuria in the 
early stages is the congestion of the kidney and in the later 
stages that it is the extension to the pelvis of the kidney, 
and the rupture of vessels in the growth. 

The character of the bleeding is subject to wide varia- 
tions. The amount may be slight and enough merely 
to discolor the urine, or it may be enough to make the 
urine appear to be pure blood. In some cases there are 
sudden changes from clear urine to a marked hematuria, 
suggesting that a blood clot had temporarily obstructed 
the ureter. The collection of blood clots in the bladder 
may give rise to bladder irritability, tenesmus, frequent 
urination, etc. 

There may be a history of a single attack of hematuria 
and no further bleeding. For example, McCosh reported 
a case in which there was an attack of hematuria and no 
further bleeding until shortly before operation. Usually 



CANCER OF THE KIDNEY 305 

the attacks of bleeding in the early stages are at intervals 
of a few weeks or possibly months, and as the disease 
advances, the intervals become shorter until finally the 
bleeding is more persistent. 

The duration of the bleeding may extend over a number 
of years. Herb reported a case of hypernephroma at 
the Mayo Clinic in which hematuria had been present for 
ten years. Garceau speaks of a similar case of Israel, 
in which the bleeding had extended over the same period. 
In most cases it is probable that the bleeding does not 
last over one year. 

The bleeding does not seem to be caused by exercise 
or bodily movements, as is frequently the case with 
renal calculi, but usually comes on spontaneously, possibly 
at night. Direct injury seems to have been the cause of 
the first attack of bleeding in some cases. 

Pain. — In the early stages pain is frequently absent, 
especially in children. Morris states that it was the 
first symptom in 35 per cent, of the cases. In Garceau's 
series pain was definitely stated to be the first symptom 
in 20 per cent, of the cases. 

The pain is usually referred to the lumbar region, and 
from there it may radiate to the thorax, or down to the 
pelvis, or to the lower extremity. 

It may be a dull, continuous pain; it may be inter- 
mittent or it may be colicky. 

There are various causes for the pain. At first it is 
probably due to the congestion of the kidney. In the 
late stages the pain may be caused by the pressure of the 
primary growth, or its metastases, on the neighboring 
nerves. A clot of blood obstructing the ureter may cause 
a distinct renal colic. Hemorrhage into the tumor may 
cause pain by distending the growth and the kidney. 

The pain does not seem to be influenced by exercise 
or position. 

Tumor. — At an early stage no tumor is felt, but ulti- 
mately the growth reaches a size that makes it easily 
palpable. In Garceau's series of 1.76 cases i1 was definitely 

20 



306 CANCER OF KIDNEY, BLADDER, PROSTATE 

stated to be present in 143, absent in 17, and not men- 
tioned in 16 cases. 

The growth at first retains the general shape of the 
kidney, and it may reach considerable size before the 
original contour is lost. 

The tumor is at first in the lumbar region, but as it 
increases in size it grows toward the anterior abdominal 
wall, as that is the direction of least resistance. 

If the tumor starts in the upper pole of the kidney 
it is at first situated high and concealed by the ribs, 
later it fills the entire space between the ribs and the 
iliac bone. 

The size of the tumor is frequently large; in fact, 
hypernephromata are frequently among the largest 
abdominal tumors. 

Normally the colon is situated in front of the kidney, 
and this is usually the relation that it retains to a tumor 
of the kidney. The colon is usually pushed somewhat 
inward as well as forward if the growth reaches a large 
size. 

The tumor is smooth and regular in the early stage 
of the disease, but after it has broken through its capsule 
it is more irregular and nodular. Its consistency may be 
hard or soft or cystic. 

Urine. — Blood is present in more than 50 per cent, 
of the cases, in varying amounts, as has been described. 
Pus is present in those cases in which there is a pyelo- 
nephritis. This condition is unusual. 

The amount of the urine is usually unchanged. There 
may be a temporary or a permanent obstruction to the 
passage of urine from the affected kidney. If it is tempor- 
ary it is usually due to an obstruction caused either b} r 
a blood clot, or more rarely by a piece of the tumor itself. 
Permanent obstruction is due to involvement of the 
ureter by the extension of the growth, and is an unusual 
complication. Garceau records a case of this kind in 
which there was total anuria on the affected side. 



CANCER OF THE KIDNEY 307 

Cystoscopic examination may give information of value. 
If blood is seen coming from the ureter it demonstrates 
that the hematuria is caused by a kidney and not a 
bladder lesion, and also shows which kidney is diseased. 

Varicocele. — Guyon, in 1881, and Morris, independently 
in 1884, called attention to the presence of varicocele 
in renal tumors. It may be due to pressure or thrombi 
in the spermatic or other veins as a result of the growth. 
It is of special suggestive value when it is on the right 
side, which is the unusual side for a varicocele to be 
present. 

Cachexia. — This is influenced considerably by the 
metastases. There may be jaundice if the liver or gall- 
ducts are involved. If there has been extension to the 
peritoneum, ascites will be present. The bones are 
frequently involved by secondary growths, and spon- 
taneous fractures may occur. Anemia may be increased 
by the hematuria, though usually the bleeding from the 
kidney does not cause marked anemia previous to the 
cachectic stage. 

Duration. — It is difficult to determine the duration 
of a hypernephroma, because the onset may give no 
symptoms, and the growth not be suspected until it has 
existed for some time. 

In 32 cases in Garceau's series in which nephrectomy 
was performed the average duration from the beginning 
to the end was three and one-half years. In this series 
the total duration of two cases was less than one year, 
of 10 cases between one and two years, and of 2 cases 
more than ten years. 

In another series of 18 cases reported by Garceau in 
which no kidney operation was performed, and in which 
there wen' metastases-, mostly in the bones and liver, 
the average duration of the disease was only one and a 

quarter years. 

Diagnosis. With renal calculus the kidney is ordinarily 
not as greatly increased in size as in a hypernephroma. 

The hematuria is less marked and is increased by exercise, 



308 CANCER OF KIDNEY, BLADDER, PROSTATE 

etc. The pain is more characteristically of the colicky 
type. The history of the passage of a stone from the 
kidney or bladder is of suggestive value. X-raj^ pictures 
may be of definite diagnostic value. It must be remem- 
bered that a calculus may exist together with the hyper- 
nephroma. 

Renal tuberculosis does not usually cause as great 
enlargement of the kidney as a hypernephroma. The 
bacteriological examination of the urine, and the in- 
oculation of animals if necessary, should determine the 
presence or absence of tuberculosis. 

Prognosis. — This is unfavorable even after operation. 
Of the 74 cases in Garceau's series who survived the 
operation, and whose subsequent source was known, 43 
cases had died, 33 from metastases and 10 from various 
causes, and 31 were still alive. Most of the latter were 
recent cases. Of the deaths from metastases, 17 were 
in the first year, 8 in the second, 6 between the second 
and sixth years, and 1 after the seventh and the tenth 
years. Hypernephromata follow the usual course of 
malignant growths in regard to metastases, the largest 
number in the first year and a few very late. 

Scudder reported 12 cases of hypernephroma which 
were removed, and all excepting one recent case died of 
metastases. 

Treatment. — The operative removal of the affected 
kidney offers the only hope of a cure. As in other malig- 
nant conditions the earlier the operation the more favor- 
able is the ultimate outcome. 

The operative mortality is high. The tumor often 
reaches a large size, and its removal is necessarily an 
extensive operation. In Garceau's series of 176 cases 
there were 143 nephrectomies with 33 operative deaths, 
or a mortality of 23 per cent. In this series are included, 
some cases in a period of imperfect technique, and the 
present mortality would be somewhat lower. 



SARCOMA OF THE KIDNEY 309 

CARCINOMA OF THE KIDNEY. 

True carcinoma, starting probably in the renal tubules, 
is one of the forms of malignant tumor of the kidney. 
The frequency with which it is recorded depends on the 
classification of the hypernephromata. If none of these 
tumors is considered carcinoma, then carcinoma of the 
kidney is rare. Garceau, who groups all hypernephromata 
separately, found in a series of 42 malignant renal tumors, 
33 hypernephromata, 3 carcinomata, 2 sarcomata, and 
4 papillary adenomata. 

Symptoms. — These are practically the same as those 
of hypernephromata, and it is rarely possible to differen- 
tiate clinically the two tumors. Carcinoma of the kidney 
runs a rapid course and does not reach the large size 
sometimes attained by the hypernephromata. 

Treatment. — The removal of the kidney offers the only 
hope of a permanent cure. The prognosis, however, is 
very bad. 

SARCOMA OF THE KIDNEY. 

It is not possible to state the frequency with which 
sarcomata of the kidney occur, because in the literature 
some writers have included cases of hypernephromata 
and cases of other tumors of apparently embryonic 
origin as sarcomata. 

Pure sarcomata of the kidney which are not associated 
either with hypernephromata or other tumors of embryonic 
origin do occur. They may be of the round- or spindle- 
celled variety. Garceau reported 2 cases of sarcoma 
in a series of 42 malignant tumors of the kidney. 

Sarcomata of the kidney are most frequent in early 
life. Young records 2 cases, one eighteen months and the 
other four years of age. 

Symptoms. — These are practically the same as the 
symptoms of hypernephromata, from which it is usually 
impossible clinically to diagnose sarcoma of the kidney. 
Sarcoma of the kidney is usually seen in early life, though 



310 CANCER OF KIDNEY, BLADDER, PROSTATE 

it occurs in adults. The course is usually rapid and 
quickly fatal. 

Treatment. — The early removal of the growth offers 
the only hope of a cure. The prognosis, as with other 
malignant tumors of the kidney, is bad. 



MALIGNANT ADENOMA OF THE KIDNEY. 

Histologically this tumor closely resembles the benign 
adenoma. Clinically, however,' it shows definite char- 
acteristics of a malignant growth. It is an infrequent 
form of kidney tumor. 

The symptoms and treatment are similar to those 
of other malignant tumors of the kidney. It does not 
form the large growths seen with hypernephromata. 

In addition to the tumors of the kidney that have 
been described, there are growths of embryonic origin 
that are occasionally seen which have some character- 
istics of malignant tumors. 

In the pelvis of the kidney and ureter, an epithelioma 
is occasionally seen. 

CARCINOMA OF THE URINARY BLADDER. 

Incidence. — In Bashford's statistics there was one 
death from a malignant growth of the bladder or urethra 
in each 55 cancer deaths. This is approximately the fre- 
quency with which malignant vesical tumors are recorded 
by different writers. 

Sex. — In Bashford's statistics the proportion of males 
to females was as 2.2 to 1. In Judd's series of 114 
bladder tumors (three of which were benign) there were 
84 males and 30 females. 

Age. — The ages of 111 cases of malignant growths 
of the urinary bladder in Judd's series are shown in the 
following table: 



CARCINOMA OF THE URINARY BLADDER 311 



10 to 20 years 3 cases. 

20 to 30 " 5 " 

30 to 40 " 11 " 

40 to 50 " 16 " 

50 to 60 " 34 " 

60 to 70 " 29 " 

70 to 80 " 12 " 

80 to 90 " 1 " 



111 



The average of these cases was fifty-three years. The 
age of the youngest with carcinoma, was seventeen years, 
and the oldest, also with carcinoma, was eighty-three 
years. 

Etiology. — The cause of malignant tumors of the 
bladder are probably the same as in other organs of the 
body. Chronic inflammation and chronic irritation are 
frequently referred to as etiological factors, and those 
agents which cause these conditions are believed to 
influence the formation of malignant growths. 

Vesical Calculi. — Calculi seemed to have caused cancer 
in some cases, though the percentage is apparently not 
large. In Judd's series of 111 malignant growths, vesical 
calculi were present in only 2 cases. In these 2 cases, 
however, the history of stone was longer than that of 
the tumor. 

Parasites. — There are frequent references in the litera- 
ture to the influence of bilharzia, a species of trematodes 
in the development of cancer of the bladder. 

This parasite according to Stiles is found in Africa, 
Asia, Cuba, Porto Rico, Panama and probably more 
generally in tropical and subtropical countries. 

The parasites or their ova work into the bladder, as 
well as into other organs, and hematuria is one of the 
common symptoms. It is probable that the ova act as 
irritants to the bladder mucous membrane, and the 
cancer is caused by the chronic irritation or the chronic 
cystitis. It must not be assumed that all cases of bil- 
harziosis develop vesical growths. Wolff quotes Goebel, 



312 CANCER OF KIDNEY, BLADDER, PROSTATE 

who found 89 vesical tumors in 1684 cases of bilharziosis, 
about 50 per cent, of which were malignant. 

Chemical Irritation. — By absorption the mucous mem- 
brane of the bladder of workers in aniline dyes, naphthol, 
and other coal-tar products is irritated, and cancer of the 
bladder may result. 

Pathology. — The most common varieties of malignant 
tumors of the bladder are the papilloma, carcinoma, and 
sarcoma. Sarcomata are rare. 

Papilloma. — These are the most frequent of the bladder 
tumors. There is a central trunk composed of fibrous 
tissue, bloodvessels, etc., and covered with transitional 
epithelium. From this central trunk, there are various 
branches, forming a villous tumor. 

In size the papillomata vary from a split pea to an 
orange. They are most frequently situated at the base 
of the bladder, often near the ureteral orifices, and rarely 
on the fundus. The tumors may be either pedunculated 
or sessile and are frequently (40 per cent.) multiple. 

Histologically these tumors are benign, but clinically 
they have several characteristics of malignant growths, 
and they should be treated as such. If they are removed, 
they tend to recur, sometimes at the place of the original 
growth, often in another part of the bladder. The recur- 
rences may be multiple, suggesting that they are the 
result of the implantation of tumor cells on the bladder 
mucous membrane. 

There is a great tendency for the papilloma to undergo 
a carcinomatous change, and doubtless many of the 
carcinomata began in a papilloma. 

Carcinoma. — These growths in the bladder appear in 
two forms: the papillomatous and the infiltrating. The 
jmjnllomatmis form suggest a transformation of a benign 
villous tumor, but some are doubtless malignant from 
the start. In carcinoma the villi are more stunted, and 
there is a greater tendency to involve the bladder wall 
than in the papilloma. 

The infiltrating carcinoma takes the form of an ulcera- 



CARCINOMA OF THE URINARY BLADDER 313 

tion surrounded by an elevated margin. It may extend 
and involve a large part of the bladder. 

Sarcoma of the bladder is rare. It is most frequent in 
early life. In Judd's series of 111 cases of malignant 
tumors of the bladder, there was no case of sarcoma. 

Metastases. — The metastases of vesical tumors occur 
late and are mostly through the bloodvessels, as there are 
very few lymphatic vessels in the bladder. 

Symptoms. — Hematuria. — This is the characteristic 
symptom of all malignant tumors of the bladder. In 
papillomata it may be the only symptom. The blood is 
usually well mixed with the urine. The amount of blood 
varies from a small discoloration of the urine to a large 
amount. At the end of micturition nearly pure blood may 
be passed. There may be an attack of hematuria, and 
no repetition of it for some weeks or months. The hema- 
turia appears without apparent cause, and does not 
seem to be influenced by exertion or movement as with 
vesical calculi. The absence of other symptoms than the 
hematuria, is most characteristic of papilloma of the 
bladder. 

In carcinoma, certainly after the disease is well ad- 
vanced, the bleeding is more continuous and associated 
with other symptoms. 

In Judd's series, including both carcinomata and 
papillomata, hematuria was the initial symptom in 47 
per cent, of the cases. Howard states that hematuria 
is the first symptom in 90 per cent, of cases of carcinoma 
of the bladder. 

Frequency of Urination. — Frequent urination was 
present in 57 cases in Judd's series. This is a common 
symptom of carcinoma of the bladder and is due in part 
to the new growth and in part to the accompanying 
cystitis. It is sometimes present with clear urine and no 
signs of cystitis. 

Retention. — Retention of urine may be caused by an 
obstruction by a pedunculated papilloma or by the 
extension of the carcinoma to the urethra. It is an 
infrequent symptom. 



314 CANCER OF KIDNEY, BLADDER, PROSTATE 

Pain. — Pain may be due to the tumor, to the cystitis, 
or to the blood clot. It was present in 88 of Judd's cases. 
It may be constant or only with micturition. 

Urinary Analysis. — Pieces of tumor in the urine are 
sometimes found in cases of papilloma. If they are found, 
they are diagnostic. The amount of blood may be only 
microscopic but usually the quantity is large. Pus is 
more frequently present in the ulcerated carcinoma 
than in cases of papilloma of the bladder. 

Cystoscopic examination will usually establish the diag- 
nosis. If necessary in some cases a piece of the growth 
can be removed for microscopic examination. 

Duration. — In Judd's 111 cases the average duration 
of symptoms before the patient came for treatment was 
36.59 months. Fourteen cases gave a history of over five 
years. This long duration indicates that the first symp- 
toms were of a benign lesion, as a malignant growth 
would not average such a long course. Howard states 
that the average duration of life after the first symptoms 
of a carcinoma is under three years. 

Prognosis. — The immediate and ultimate results of 
operative treatment of malignant tumors of the bladder 
depend on the extent of the growth. Unfortunately most 
cases are operated upon in an advanced stage, when 
the operative mortality is high and early recurrence is 
frequent. 

Treatment. — Papillomata of the bladder should always 
be removed. It is probable that most of them would 
ultimately become malignant if not removed. Further- 
more, it is not possible to determine the nature of the 
growth, and to know that it is not malignant, except 
by removal. 

For small multiple papillomata and for recurrences 
the high-frequency current is of special value. It is 
also used for single tumors. The removal of the growth 
and a portion of the bladder wall, through a suprapubic 
or a transperitoneal incision, is probably the best operation 
for a papilloma of the bladder. Care must be taken to 



CARCINOMA OF THE PROSTATE 315 

avoid the implantation of the tumor cells on the bladder 
mucous membrane. 

For carcinoma of the bladder the removal of the growth 
with a part or the whole of the bladder is the most promis- 
ing treatment. 

If the entire bladder is removed the ureters are im- 
planted into the vagina, or are brought out in the lumbar 
region. The implantation of the ureters into the rectum 
is associated with too great risk of renal infection. 

The palliative treatment is directed to the relief of 
symptoms. For the hematuria, irrigation of the bladder 
may be necessary. If it is impossible to wash out the 
blood clot an evacuator may be used, or a suprapubic or 
vaginal drain may be indicated. 

For the pain it is best to use morphin and bladder 
irrigations. It may be necessary to drain the bladder, 
but this should not be done unless unavoidable, as it 
may increase and not relieve the discomfort. 



CARCINOMA OF THE PROSTATE. 

Frequency. — In Bashford's mortality statistics there 
were 293 deaths from cancer of the prostate in a total of 
33,788 male cancer deaths, or 0.86 per cent, of the cancer 
mortality of males. 

Young in private practice found GS cases of carcinoma 
of the prostate during a period in which he had 250 cases 
of benign hypertrophy of the prostate; that is, 21 per cent., 
were malignant. Wilson and McGrath found in a series 
of 468 reexamined prostates 16.5 per cent, were malignant. 
These statistics indicate that cancer of the prostate is 
more frequent than formerly believed. 

Most of the malignant growths of the prostate are 
carcinomata. Sarcomata occur in the prostate only rarely. 

Age. — The ages of the 293 cases in Bashford's statistics 
taken from the mortality records of England and Wales 

are given in the following table: 



316 CANCER OF KIDNEY, BLADDER, PROSTATE 
Under 25 years 1 case. 



25 to 35 
35 to 45 
45 to 55 
55 to 65 
65 to 75 
75 to 85 
85 



2 cases. 



26 
81 
112 
62 
5 

293 



It will be noticed by these statistics that cancer of the 
prostate occurs at an advanced age, even later than most 
cancers of other organs. 

Malignant tumors of the prostate, however, occur in 
early childhood. These early cases are usually sarcomata. 

Etiology.— Hypertrophy of the prostate is regarded as 
a possible factor in the development of carcinoma of the 
prostate. It is, of course, impossible to prove definitely 
the relationship. By analogy, however, chronic inflam- 
mation of the prostate has the same influence on the 
development of cancer as chronic inflammation elsewhere. 

A chronic posterior urethritis resulting from a gonor- 
rheal infection may be influential in causing a cancer 
of the prostate in the same manner. 

Pathology. — Carcinoma of the prostate may be of the 
simple or scirrhus variety. It begins usually in the 
posterior lobe. Usually the prostate is increased in size; 
it may be of normal size, and sometimes it is atrophic. 
There may be a number of foci throughout the gland 
giving it a nodular appearance. In consistency the 
gland is usually hard. The hardness is of diagnostic help. 

In some cases the extension of the growth may be slow, 
and it may remain limited to the gland itself. In other 
cases it rapidly extends through the capsule of the prostate 
and involves the bladder, the rectum, and the pelvic 
glands, so that in a short time the entire pelvis is infiltrated 
with the malignant growth. As a rule, the extension of a 
prostatic cancer is first backward, involving first the 
seminal vesicles and ejaculatory ducts and then the 



CARCINOMA OF THE PROSTATE 317 

bladder. The ureters may be obstructed. The rectum 
is probably involved late or not at all. 

Metastases. — The metastases occur most frequently 
in the bones, especially the vertebrae, femur, and humerus. 
Of the lymph glands, the iliac, inguinal, and sacral are 
the first involved. Metastases in the viscera are unusual. 
The liver and lungs are most frequently involved. 

Symptoms. — The early symptoms of carcinoma of the 
prostate are similar to those of hypertrophy. There 
may be difficulty in starting the act of micturition, 
decrease in the force and increase in the frequency of 
the act. There may be residual urine in the bladder, 
though this is not a usual symptom. There may be 
incontinence late in the disease. The disturbance with 
urination is progressive and without remissions. 

Hematuria. — Hematuria is present in probably 5 to 
10 per cent, of the cases of prostatic cancer, and generally 
indicates extension of the growth and ulceration of the 
bladder. That is, it ordinarily indicates an advanced stage 
of the disease. The amount of bleeding is not extensive. 

Pain. — This may be the first symptom. It is at first 
slight, but increases in severity. It may be referred to the 
penis, bladder, thigh, testes, rectum, legs, etc. When 
established it is usually constant, and is often increased 
but not relieved by micturition. At this stage it is 
probably due to pressure on nerves. 

In a late stage there may be retention of urine with 
cystitis, which gives additional and different pain. 

Digital Examination. — The size and shape of the gland 
do not assist greatly in the diagnosis as they are both 
similar to that of a benign hypertrophy. In carcinoma 
the enlargement is usually backward between the seminal 
vesicles and this may be detected by rectal examination 
in some cases. At a later stage, when the growth has 
penetrated the capsule of the prostate, the normal shape 
of the gland may be lost. 

The consistency of the prostate is of the greatest im- 
portance in the differential diagnosis. The stony hardness 



318 CANCER OF KIDNEY, BLADDER, PROSTATE 

of carcinoma usually involves the entire gland but may 
be limited to one part, and generally distinguishes it 
from hypertrophy. 

The surface of the prostate in the early stage is usually 
smooth, later it may be nodular. The irregular and nodu- 
lar surface suggests that the disease has penetrated the 
capsule. 

Young states that when the prostate has been exposed 
at operation, carcinoma can usually be diagnosed by 
palpation and inspection. If necessary a piece of tissue 
can be removed for frozen section before continuing the 
operation. 

Prognosis. — This is unfavorable even if the case is 
seen at an operable stage. In most cases there is an early 
recurrence. There is, however, definite prolongation of 
life and an increase of comfort, obtained by operation in 
many cases. 

Treatment. — The radical operation consists in the 
removal of the prostate gland together with the seminal 
vesicles, ejaculatory ducts, and the base of 'the bladder. 
This operation is an extensive one and the results are still 
uncertain. 

The treatment of the inoperable cases is directed to 
the symptoms. For pain, morphin and belladonna will 
be necessary. If there is frequent and painful urination, 
catheterization and irrigation of the bladder may be 
necessary. Only soft catheters should be used. In 
some cases a suprapubic drainage of the bladder is 
necessary. 

CARCINOMA OF THE PENIS. 

Frequency. — The frequency of carcinoma of the penis is 
given by different writers between 1 and 3 per cent, of all 
carcinomata in males. In Bashford's statistics, malignant 
disease of the penis is recorded with that of the testes, 
and as malignant disease of these two organs occurred 
only 409 times in a total of 33,788 cancer deaths, or approx- 
imately in the ratio of 1 in 72, and as the testes are more 



CARCINOMA OF THE PENIS 319 

frequently involved than the penis, the percentage of 
carcinoma of the penis is small. 

Bashford's cases must have been considerably less 
than 1 per cent, of the total male cancer deaths. The 
penis is therefore an infrequent location for a malignant 
disease. 

Age. — Creite tabulated the ages of 616 cases from the 
literature of eight writers, of which cases there were 
probably some duplicates, and found the largest mimber 
of cases of carcinoma of the penis, 30.5 per cent., in the 
decade between fifty and sixty years. He himself reported 
one case of carcinoma of the penis starting in the corpora 
cavernosa in a child two years of age. 

Metastases. — The inguinal glands are generally the 
first to be involved, but usually they are not diseased 
until the growth has existed for some months. Kiittner 
states that in some cases the pelvic lymph nodes without 
the inguinal glands are involved. 

Etiology. — Phimosis. — This is usually given as an 
important predisposing cause of carcinoma of the penis. 
The lack of local cleanliness and the accumulation of 
secretion beneath the prepuce is believed to cause the 
irritation that results in the development of the carcinoma. 
Strong evidence of the influence of phimosis in carcinoma 
of the penis comes from India, where the disease seems to 
be more prevalent than in Europe and America. It is 
stated that in India, carcinoma is common among the 
Hindoos who do not practice circumcision, but is very 
rare among the [Mohammedans who are circumcised. 

Scars. — Scars resulting from injuries, venereal sores, 
syphilis, etc., are also believed to be etiological factors, 
acting as scars elsewhere. 

Leukoplakia of the glans penis has apparently been the 
precancerous lesion in some reported cases. 

Duration. — The course of carcinoma of the penis is 
usually slow. The prognosis of the operative removal is 
much more favorable than in most operations for malig- 
nant disease. 



320 CANCER OF KIDNEY, BLADDER, PROSTATE 

Pathology. — Most cases of carcinoma of the penis are 
epitheliomata. Glandular carcinomata are described 
though rarely. 

The location of a beginning carcinoma of the penis is 
most frequently in one of three places: (1) the glans penis, 
especially in the sulcus, (2) on the prepuce, (3) in the 
corpora cavernosa. 

The form may be that of a cauliflower or papillary 
growth, or of an ulceration. 

In the beginning there is most frequently a small wart 
or thickening of the epithelium, which becomes indurated 
and extends to the deeper parts, and later takes one of the 
forms stated. At an advanced stage the penis may be 
largely destroyed and the ulceration may extend to the 
abdominal wall and scrotum. 

Treatment. — The radical removal of the growth is the 
only proper treatment. This usually means the amputa- 
tion of the penis and the removal of the inguinal glands. 
Excision of the growth without amputation of the penis is 
sometimes advised, but the results following this less 
extensive removal cannot be as favorable as the amputa- 
tion of the perns, and should not be done unless the growth 
is seen early and favorably located on the prepuce. Sub- 
sequent to the operation the case should be carefully 
watched for any local recurrence, as a subsequent more 
radical operation might save the patient. 

CANCER OF THE TESTIS. 

The testis is an infrequent location for either a primary 
or a secondary malignant growth. In Bashford's statistics 
the malignant tumors of the penis and testis together 
constituted 1.4 per cent, of the male cancer deaths. 
Howard states that only 0.06 per cent, of all male patients 
admitted to the London Hospital were suffering from 
a malignant growth of the testis. 

Age. — Carcinoma of the testis is a disease of adult life, 
occurring most frequently in the decade between thirty- 



CANCER OF THE TESTIS 321 

five and forty-five years. Sarcoma of the testis occurs 
in earlier years; a number of cases are reported in early 
childhood. 

Trauma. — Injury seems to be the exciting factor in an 
important percentage of the cases of malignant tumors 
of the testis. Lowenstein records a number of cases of 
carcinoma and of sarcoma of the testis which apparently 
resulted from injury. The time which elapsed between 
the injury and the development of the malignant tumor 
varied from five weeks to a number of years. It is 
probable in some cases that the injury directed attention 
to a preexisting tumor and was not the direct cause of 
it. An undescended testis, that is, one that is retained 
in the abdomen, is more frequently affected by a malignant 
growth than one that is normally situated. 

Pathology. — The classification of malignant tumors of 
the testis is difficult, as it is complicated by the teratomata, 
the pathology of which, in the testis as elsewhere, is not 
clear. In addition to the teratomata, sarcomata and 
carcinomata are the most frequent malignant tumors of 
this organ. 

Sarcoma. — Formerly this was considered to be more 
frequent in the testis than carcinoma, but at present 
it is believed to be less frequent. Formerly under the 
name of alveolar sarcoma, were grouped tumors that are 
now classed as carcinoma. Round-celled sarcoma is the 
most frequent variety in the testis. Spindled-celled occurs 
but very rarely. The tumor usually grows rapidfy and 
often involves both testes. Probably many of the cases 
classified as sarcoma really belong to the class of 
teratomata. 

Carcinoma. — The medullary carcinoma is the most 
common and the scirrhus the less frequent variety. 
The testis is increased in size, and in the early stages 
freely movable from the skin. Later the skin becomes 
adherent, and ulceration of the growth occurs. As with 
sarcomata, probably many cases diagnosed as carcinoma 
are really teratomata. 
21 



322 CANCER OF KIDNEY, BLADDER, PROSTATE 

Teratoma (Mixed Tumor). — The origin of these 
tumors is still the subject of wide differences of opinion. 
Each theory seems to have some objection and fails to 
adequately explain some important points. Formerly 
it was believed that these growths resulted from fetal 
inclusions. That is, a second fetus had partly developed 
and formed the nucleus from which the tumor developed. 

Later the theory of parthenogenesis was used to explain 
the origin of these growths. It was believed that certain 
undeveloped cells, partially fertilized in the testis, pro- 
duced the teratoma. 

Ewing, after an extensive analysis of the various 
hypotheses as to the origin of teratoma, concludes "that 
teratoma testis arises from sex cells in the neighborhood 
of the rete, whose normal development into spermatogoma 
has been suppressed but whose potencies remain intact 
and ready to express themselves in the various forms of 
simple and complex teratomata." The teratomata are 
derived from two or all three original cell layers, and may 
contain various tissues such as hair, muscle, teeth, carti- 
lage, epidermis, etc. In these tissues, there may be 
developed growths resembling either carcinoma or sar- 
coma. Many cases called sarcoma or carcinoma are 
undoubtedly teratomata. 

Symptoms. — Pain. — In the early stage there is no pain 
from the tumor itself except that which is caused by the 
increased size and weight of the growth. This causes 
a dragging pain in the back or groin. Later there may 
be abdominal pain from metastases. 

Testicular sensation is usually absent in the later stages 
when the growth has well developed, and most of the 
testis has been destroyed. 

At first the growth is smooth and freely movable, 
but later becomes irregular and adherent to the skin, 
and still later ulcerated. 

There may be an effusion into the tunica vaginalis 
though this is not common. The testis itself is usually 
hard, though it may be cystic. 



CANCER OF THE TESTIS 323 

Prognosis. — Some of the tumors of the testis are very 
malignant and form metastases early. In some cases 
the primary tumor in the testis is found only at autopsy. 
It is not possible to give definite statement in regard to 
the percentage of cures following operation for malignant 
growth of the testis. If the case is operated on early, it 
should be associated with a low operative mortality and 
a high percentage of cures. 

Treatment. — The only curative treatment is the removal 
of the testis. The removal of the testis is indicated, 
not only as a curative, but also as a palliative measure. 
The removal of the testis is associated with a small risk 
and it prevents the ulceration that will ultimately occur 
in most cases. It is better therefore to remove the external 
growth if possible, as it adds to the comfort of the patient. 

LITERATURE. 

Creite. Dcut. Zeit. f. Chir., Band Ixxix, S. 305. 
Ewing. Surgery, Gynecology and Obstetrics, xii, 258. 
Garceau. Tumors of the Kidney. 
Goebel. Zeit. f. Krebs., Band iii, S. 369. 
Grawitz. Virchows Archiv, Bd. xciii, S. 39. 
Herb. Amer. Jour. Med. Sci., cxxix, 1011. 
Howard. Choyce's Surgery, ii, 870. 
" Choyce's Surgery, ii, 942. 

Judd. Collected Papers, Mayo Clinic, 1912. 
Kiittner. Beitr. f. klin. Chir., Band xxvi, S. 1. 
Lowenstein. Ueber Unfall und Krebskrankheit. 
McCosh. Annals of Surgery, xxxix, 300. 
Morris. Surgical Diseases of the Kidney and Ureters. 
Scudder. Annals of Surgery, xliv, 855. 
Stiles. Osier's Modern Medicine, i, 550. 

Stoerk. Beitriige z. Anat. u. alleg. Path., 1908, Bd. xlii, S. 393. 
Sudeck. Virchows Archiv, Band cxxxvi, S. 293. 
Sutherland. Indian Medical Gazette, May, 1902, p. 164. 

[ndian Medical Gazette, May, 1905, p. 163. 
Wilson. Collected Papers, Mayo Clinic, 1910. 
Wilson and McGrath. Collected Papers, Mayo Clinic, 1911. 
Young. Osier's Modern Medicine, vi, 347. 
" Osier's Modern Medicine, vi, 300. 



INDEX 



Acetone in carcinoma of cervix, 

159 
Adenocarcinoma of stomach, 219 
Adenomata of liver, 293 
malignant, of kidney, 310 
as precancerous lesions, 63 
Adhesions, extension of cancer 

by, 80 
Adrenal "rests," 301 
Age in development of cancer, 38 

extremes of, 40 
Alcohol in mouth cancer, 175 
Anastomosis, intestinal, 258 
Animals, susceptibility of, to 

cancer, 38 
Appendix, carcinoma of, 268 
etiology of, 268 
pathology of, 270 
symptoms of, 272 
Arteries, metastases by, 77 
Ascites in carcinoma of gall- 
bladder, 289 
of liver, 295 



B 



Benign growths as precancerous 
lesions, 59 
tumor, definition of, 19 

occurring with malignant, 
101 
Bile duct, common, carcinoma of, 
290 
ducts, carcinoma of, 284, 286 
Bladder, involvement of, in car- 
cinoma of cervix, 139 
urinary, carcinoma of, 310 



Bladder, urinary, carcinoma of, 
duration of, 314 
etiology of, 310 
metastases of, 313 
pathology of, 312 
prognosis of, 314 
symptoms of, 312 
treatment of, 314 
urine in, 314 
Blood in carcinoma, changes and 
causes of, 86 
of stomach, 230 
Bone, traumatic cancer in, 35 
Bougies in diagnosing carcinoma 

of esophagus, 209 
Bowels in carcinoma of stomach, 

229 
Breast, cancer of, lactation and, 
106 
carcinoma of, 103 
age and, 104 
in both breasts, 1 10 
civil state and, 104 
etiology of, 104 
extension of, 111 
to bones, 113 
lymphatic, 111 
visceral, 113 
frequency of, 103 
location of, 109 
medullary, 109 
mortality statistics of, 104, 

123 
pathology of, 108 
permanent cure of, 124 
permeation of, 115 
recurrences of, 124 
relation of affected sides to, 

109 
Ilnciitgen rays in, 121 



326 



INDEX 



Breast, carcinoma of, scirrhus, 
108 
sex and, 104 

statistics of cures of, 124 
symptoms of, 117 
treatment of, 120 
radium in, 121 
mastitis of, 105 

chronic cystic, 106 
multiple tumors in, 101 
sarcoma of, 103, 125 
trauma in relation to cancer of, 
36, 108 
Buccal cavity, carcinoma of, 169 

etiology of, 170 
Burns in carcinoma of lip, 189 



Cachexia, 84, 88 

in carcinoma of stomach, 229 

in malignancy of kidney, 307 

Calculus in carcinoma of bladder, 

311 
Cancer k deux, 64 
age and, 38 
anthracine, 28 
antitoxic substances in, 92 
blood changes in, 86 
care in manipulation of, 68 
cause of, 26 

cells, fate of, in circulation, 82 
in lymphatic glands, 83 
quiescence of, for long periods, 

98 
scattering of, 69 
characteristics of, 18 
in city and country, 48 
coma in, 89 
contagiousness of, 64 
cure of, after incomplete opera- 
tion, 95 
definition of, 17 
emaciation in, 88 
extension of, by adhesions, 80 
by contact, 79 
by implantation, 79 

in mucous membrane, 80 
in serous membrane, 79 
on skin, 82 
families, 42 



Cancer, fever in, 89 
frequency of, 19 
geographical distribution of, 44 
heredity in, 41 
increase of, 19, 20 
infection by wounds, 66 
influence of civilization on, 22 
juice, 64, 85 
in mice, 65 
organisms in, 26 
pain in, 88 
permeation of, 114 
post-traumatic, 36 
precancerous lesions in, 50 
predisposition to, 37 
rate of growth in, 18 
recurrences of, 67 
relation to race to, 44 
relative deaths in, 20 
removal of piece for diagnosis 

of, 69 
sex and, 40 

spontaneous cure of, 90 
after erysipelas, 97 
of primary growth, 96 
statistics of, general, 19 

mortality, 39, 46 
theories of, 23 
toxins of, 85 
varieties of, 17 
Carcinoma, age incidence of, 

40 
of ampulla of Vater, 291 
of appendix, 268 
of bile ducts, 284, 286 
of breast, 103 
of cervix uteri, 137 
of cheek, 183 
of duodenum, 247 
of esophagus, 204 
of face, 194 
in fibroma uteri, 62 
of fundus uteri, 142 
of gall-bladder, 284 
of gums, 186 
of ileum, 250 
of intestines, 244 
of jejunum, 250 
of kidney, 309 
of large intestine, 251 
of lips, 187 
of liver, 284 



INDEX 



327 



Carcinoma, occurrence of, with 
sarcoma, 99 
of palate, 185 
of pancreas, 297 
of penis, 318 
of prostate, 315 
rate of growth of, IS 
of rectum, 272 
spontaneous cure of, 90 
of stomach, 212 
colloid, 219 
scirrhus, 219 
of testis, 320 
of tongue, 176 
of urinary bladder, 310 
of uterus, 128 
Cardiac orifice, carcinoma of, 242 
Caustics in carcinoma of cervix, 

158 
Cautery, deep action of, 96 

in prevention of recurrence, 71 
Cervix uteri, carcinoma of, 152 
acetone in inoperable cases 

of, 159 
causes of post-operative 

deaths in, 161 
caustics in inoperable cases 

of, 158 
cauterization of, 158 
contact infection in, 81 
diagnosis of, 152 
extension of, 138 
fistulse development of, 

139 
fixation of uterus in, 139 
inoperable cases of, 140, 

157 
involvement of bladder in, 
139 
of fundus uteri in, 141 
of rectum in, 139 
of ureters in, 139 
of vagina in, 141 
metastases of, 140 
operable cases of, 153 
operation for, 156 
operative statistics of, 160 
pathology of, 137 
percentage of operability 

of, 157 
recurrences of, 162 
symptoms of, 144 



Cheek, carcinoma of, 169, 183 
Child-birth in breast cancer, 105 

trauma of, 36 
"Chimney sweepers' cancer," 27 
Cirrhosis in carcinoma of liver, 

293 
Civilization, influence of, on 

cancer, 45 
Climate, cancer and, 44 
Cohnheim theory of cancer, 23 
Colostomy in carcinoma of large 
intestine, 258 
of rectum, 282 
Coma in cancer, 89 
Concretions in carcinoma of 

appendix, 269 
Constipation in carcinoma of 
large intestine, 254 
of rectum, 275, 277 
in gastric carcinoma, 229 
Contact, extension of cancer by, 

79 
Cystoscopy, in hypernephromata, 
307 



Duodenum, carcinoma of, 247 
prognosis, 249 
symptoms, 247 
treatment, 249 
Dysphagia in carcinoma of esoph- 
agus, 207 
Dyspnea in carcinoma of esoph- 
agus, 208 



E 



Eczema followed by cancer, 53 
Emaciation, 88 

in carcinoma of esophagus, 208 
Embryonal cells, 23 
Epulis, 201 
Erysipelas in spontaneous cure 

of cancer, 97 
Esophagoscope, diagnostic use of, 

209 
Esophagus, carcinoma of, 204 
etiology of, 204 
diagnosis of, 208 
dysphagia in, 207 



328 



INDEX 



Esophagus, carcinoma of, emacia- 
tion in, 208 

extension of growth in, 206 

metastases of, 206 

pathology of, 205 

symptoms of, 207 

treatment of, 210 
Eye in sarcoma of upper jaw, 201 



Face, carcinoma of, 194 
etiology of, 194 
frequency of parts involved 

in, 196 
pathology of, 195 
symptoms of, 197 
treatment of, 197 
liquid air in, 197 
Family, cancer in, 42 
Feces in carcinoma of large in- 
testine, 256 
in sarcoma of intestines, 267 
Females, greater frequency of 

cancer in, 41 
Fever in cancer, 89 
Fibromata uteri as precancerous 

lesions, 61 

Fissures in carcinoma of lips, 189 

Fistula as precancerous lesion, 55 

with carcinoma of cervix uteri, 

139 

Flatulence in carcinoma of large 

intestine, 255 
Fundus uteri, carcinoma of, 142 
diagnosis of, 148, 150, 152 
extension of, 143 
inoperable cases of, 157 
operable cases of, 155 
operation for, 156 
operative statistics of, 161 
pathology of, 142 
recurrences of, 162 
symptoms of, 148 
treatment of, 155 



Gall-bladder, carcinoma of, 284 
ascites in, 289 
etiology of, 285 



Gall-bladder, carcinoma of, fre- 
quency of, 284 
jaundice in, 289 
pathology of, 287 
symptoms of, 288 
treatment of, 291 
sarcoma of, 287 
Gall-stones in carcinoma, 286 
Gastro-enterostomy in carcinoma 

of pylorus, 241 
Gastro-intestinal tract, contact 
cancer in, 82 
multiple tumors in, 101 
Glossitis, chronic, 51 
Gout in oral cancer, 175 
Gums, carcinoma of, 169, 186 



Hand ley's theory, 114 
Hematuria in carcinoma of blad- 
der, 313 
of kidney, 304 
of prostate, 317 

in hypernephromata, 301 
Hemoglobin, changes in, 87 
Hemorrhage in carcinoma of 
rectum, 278 
of stomach, 230 
Hemorrhoids, relation of, to rectal 

carcinoma, 274 
Heredity, 41 

in carcinoma of stomach, 215 
Highmore, antrum of, in sarcoma 

of jaw, 200 
Hydrochloric acid in carcinoma 

of stomach, 234 
Hypernephromata, 301 

diagnosis of, 307 

etiology of, 303 

hematuria in, 304 

malignancy of, 303 

prognosis of, 308 

symptoms of, 304 

treatment of, 308 

urine in, 306 



Ileum, carcinoma of, 250 
Implantation, cancer extension 
by, 79 



INDEX 



329 



Inflammation, chronic, relation 

of, to cancer production, 31 
Intestinal perforation in car- 
cinoma of large intestine, 256 
Intestine, large, carcinoma of, 
251 
etiology of, 251 
location of growth in, 252 
metastases in, 257 
mortality of, 263 
prognosis of, 257 
symptoms of, 254 
treatment of, 257 
Intestines, carcinoma of, 244 
etiology of, 244 
pathology of, 246 
statistics of, 244 
sarcoma of, 246 
etiology of, 264 
feces in, 267 
pathology of, 265 
symptoms of, 266 
treatment of, 268 
Irritation, chemical, 27 

chronic, in carcinoma of face, 
195 
of lips, 189 
of tongue, 177 
in mouth cancer, 173, 183 
physical, 29 



Jaundice in carcinoma of com- 
mon bile duct, 290 

of gall-bladder, 289 

of liver, 296 

of pancreas, 298 
Jaw, sarcoma of, 169, 197 

metastases in, 200 

mortality of, 203 

pathology of, 198 

prognosis of, 202 

symptoms of, 200 

treatment of, 202 
Jejunum, carcinoma of, 250 



Kidney, cancer of, diagnosis of, 
with calculus, 307 



Kidney, cancer of, hematuria in, 
304 
carcinoma of, 309 
hypernephromata of, 301 
malignant adenoma of, 310 
sarcoma of, 301, 309 



Lactation, relation of, to cancer 

of breast, 106 
Lactic acid in carcinoma of 

stomach, 234 
Large intestine, carcinoma of, 251 
Leukocytosis in cancer, 87 
Leukoma, 51 

Leukoplakia buccalis as a pre- 
cancerous lesion, 51, 174, 183 
Lips, carcinoma of, 169, 187 
etiology of, 187 
location of, 190 
lymphatic extension in, 190 
mortality of, 193 
pathology of, 189 
permanent cure in, 193 
prognosis of, 191 
symptoms of, 191 
treatment of, 191 
radium in, 197 
contact cancer in, 82 
Liquid air in cancer of face, 197 
Liver, carcinoma of, 284, 292 
ascites in, 295 
etiology of, 293 
jaundice in, 296 
pathology of, 293 
symptoms of, 295 
treatment of, 297 
Lupus vulgaris as a precancerous 

lesion, 53 
Lymphatic glands in carcinoma 
of breast, 119 
of cervix uteri, 140, 162 
fate of cancer cells in, 83 
metastases in, 75 
spontaneous cure in, 92 

M 

Maxes, increased cancer death 
in, 41 



330 



INDEX 



Malignant tumors, occurring with 

benign, 101 
Massage, danger in, 68 
Mastitis, chronic cystic, 106 

preceding carcinoma of breast, 
105, 106 
Metastases, arterial, 78 

in carcinoma of large intestine, 
257 

lymphatic, 75 

modes of production of, 74 

peritoneal, 78 

relative to viscera, 83 

retrograde, 78 

spontaneous cure of, 91 

venous, 77 
Moles, heredity of, 42 

as precancerous lesions, 59 
Mouse, cancer in, 65 
Mucous membrane, implanta- 
tion of cancer on, 80 
Multipara?, uterine carcinoma in, 

131 



N 



NjEvi, heredity of, 42 

as precancerous lesion, 59 
Nervous system, involvement of, 

in carcinoma of esophagus, 207 
Nipple, retraction of, 109 
Nose, involvement of, in sarcoma 

of jaw, 199 
Nullipara?, uterine carcinoma in, 

130 



Obstruction, intestinal, in car- 
cinoma of large intestine, 255, 
257 

Operation, incomplete, cure fol- 
lowing, 95 

Ovary, malignant papilloma of, 
spontaneous cure of, 91 



Paget' s disease, 53 

Palate, carcinoma of, 169, 185 



j Pancreas, carcinoma of, 297 
Papilloma, malignant, of bladder, 
312 
of ovary, 91 
Parasites in carcinoma of bladder, 

311 
Parasitic theory of cancer, 25 
Paraffin, influence of, on cancer 

development, 28 
I Penis, carcinoma of, 66, 318 
Perforation, intestinal, in car- 
cinoma of large intestine, 256 
Peristalsis in carcinoma of large 

intestine, 255 
Peritoneum, metastases in, 78 
Permeation of cancer, 114 
Phimosis, predisposing to car- 
cinoma of penis, 319 
Pipe-smoking in carcinoma of 
tongue, 178 
in development of cancer, 29, 
51 
Poikilocytosis in cancer, 87 
Polyp in carcinoma of large in- 
testine, 254 
gastro-intestinal, cancer and, 

62 
rectal, cancer and, 273 
uterine, cancer and, 62 
Precancerous lesions, 50, 59 
Predisposition, 37 
Pregnancy, influence of, on car- 
cinoma of uterus, 163 
occurring with carcinoma of 
uterus, 167 
i Primary tumors, multiple, 99 

spontaneous cure of, 96 
1 Prostate, carcinoma of, 315 
etiology of, 316 
pathology of, 316 
symptoms of, 317 
treatment of, 318 
Prussia, mortality records in, 

39 
Ptosis in carcinoma of esophagus, 

208 
Pjdorus, carcinoma of, advanced, 
241 
operable, 239 

treatment of, non-surgical, 
241 
malignant obstruction of, 236 



INDEX 



331 



Race, influence of, on cancer, 44 
Radium in carcinoma of breast, 
121 
of face, 197 
Rectum, carcinoma of, 272 
diagnosis of, 278 
inoperable cases of, 281 
mortality of, 280, 281 
operable cases of, 279 
pathology of, 275 
symptoms of, 277 
treatment of, 279 
involvement of, by carcinoma 
of cervix, 139 
Recurrence, 67 

arbitrary time limit in, 72 
by implantation, 69 
late, 72 

in operation wounds, 70 
prevention of, by cautery, 71 
time of, 71 
Red blood cells, changes in, 87 
"Rests," adrenal, 301 

embryonal, 23 
Retention, urinary, in carcinoma 

of bladder, 313 
Ribbert's theory of cancer, 25 
Roentgen rays in carcinoma of 
breast, 121 
of esophagus, 208 
of face, 197 
in development of cancer, 30 
examination in carcinoma of 
stomach, 234 



Sakcoma, age incidence and, 40 
of breast, 103, 125 
following trauma, 34 
of gall-bladder, 287 
of intestines, 246, 264 
of jaws, 169, 197 
of kidney, 301, 309 
multiple, of skin, 100 
occurrence of, with carcinoma, 

99 
spontaneous cure of, 90, 99 
of testis, 321 



Savages, cancer among, 45 
Scars, cancer occurring in, 36, 56 
Serous membranes, cancer im- 
plantation on, 79 
Sex incidence of cancer, 40 
Sinuses as precancerous lesions, 

31,55 
Skin, implantation of cancer on, 
82 
lesions followed by cancer, 31, 
53 
Smoking in production of oral 

cancer, 171, 178 
Soot, in development of cancer, 

27 
Stomach, carcinoma of, 212 
blood changes in, 230 
cardiac orifice of, 242 
contents of, analysis of, 233 
diagnosis of, 237 
etiology of, 212 
extension of, 219 
lymphatic, 220 
frequency of, 213 
hemorrhage in, 230 
location of growth in, 224 
middle of stomach, 243 
mortality of, 214, 240 
operation for, 239 
pathology of, 219 
symptoms of, 224 
treatment of, 238 
Stricture in carcinoma of rectum, 

274 
Sun's rays in development of can- 
cer, 30 
Syphilis in cancer of oral cavity, 
173, 177 



Tab in development of cancer, 28 

Teeth, extraction of, sarcoma of 
jaw and, 198 
in mouth cancer, 174, 177 
pain in sarcoma of jaw, 201 
relation of, to cancel- develop- 
ment, 51 

Tenesmus in carcinoma of rectum, 
278 

Teratoma of testis, 322 



332 



INDEX 



Testis, carcinoma of, 320 
sarcoma of, 321 
traumatic cancer in, 35 
Tobacco in cancer of buccal 
cavity, 172 
in development of cancer, 29 
Tongue, carcinoma of, 169, 176 
diagnosis of, 180 
etiology of, 176 
metastases in, 179 
pathology of, 178 
statistics of, 182 
symptoms of, 180 
treatment of, 182 
Toxins of cancer, 85 
Trades, influence of, on cancer, 

27 
Trauma in carcinoma of breast, 
108 
of large intestine, 253 
of liver, 293 
of stomach, 216 
of testis, 321 
in production of cancer, 33 
in sarcoma of breast, 125 
of jaw, 198 
Tumors, definition of, 17 
differentiation of, 19 
malignant occurring with be- 
nign, 101 



Ulcer in carcinoma of large in- 
testine, 254 
of lips, 191 
of rectum, 274 
relation of, to carcinoma of 
stomach, 217 
Ulceration, chronic, relation of, 
to cancer development, 31, 54, 
55 
Ureters, involvement of, with 

carcinoma of cervix, 139 
Urine in carcinoma of bladder, 
314 
with hypernephromata, 306 
Uterine fibromata relation of, to 

carcinoma, 61 
Uterus, carcinoma of, 128 
age and, 129 



Uterus, carcinoma of, abortions 
and miscarriages and, 133 

cervical erosions and, 136 
inflammation and, 136 
lacerations in, 134 

course of, 151 

etiology of, 128 

infection of husband and, 
66 

mixed tumors in, 101 

mortality of, 128 

in multipara?, 131 

multiple tumors in, 100 

in nulliparae, 130 

obstetrical operations and, 
134 

pathology of, 137, 142 

pregnancy in, influence of, 
129 
occurring with carcinoma, 
163 

in virgins, 130 



Vagina, contact cancer in, 81 
involvement of, in carcinoma 
of cervix, 141 

Veins, metastases by, 77 

Virgins, uterine carcinoma in, 
130 

Varicocele in tumors of kidney, 
307 

Varicose ulcers, relation of, to 
cancer, 54 

Vater, ampulla of, carcinoma of, 
284, 291 

Vomiting in carcinoma of stom- 
ach, 227 



W 

Warts, heredity of, 42 
as precancerous lesions, 59 

Weather in cancer of face, 195 
in carcinoma of lips, 189 
influence of, in development 
of cancer, 30 

Wounds, cancer infection of, 66 
recurrence of cancer in, 70 



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